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Benefits enrollment guide : active and new employees of the state of Oklahoma.

2012 Benefits Enrollment Guide 1
OKHealth – New
and Improved!
In 2012, more than ever before, Wellness and Prevention will
be gateways to your benefits. All three of the available HMO
carriers will offer a new “Wellness Alternative Plus” plan. To take
advantage of the 25 dollar per month savings off the Alternative
rates, you must complete a brief Health Risk Assessment (HRA).
That HRA will open the door to the new-and-improved OKHealth
Wellness Program and to your better health.
OKHealth has been
reinvented to be much more
flexible, interactive and user-friendly.
Free, one-on-one
health coaching is available
for state employees who
need it, while many others
will be able to “self coach”
their way to better health by using the many resources available
on the new OKHealth web site.
It’s customized! In fact, as an active state employee, you already
have your own wellness page that can be tailored to fit your
individual needs! For a free, no-obligation preview of what’s
available, go to www.ebc.ok.gov and go to the OKHealth section.
The new web site includes social network functions where you
can interact with other state employees who share your wellness
goals. It has channels dedicated to weight management, fitness,
nutrition, stress management, financial health and even a place
to find a good laugh. YOU are the one who will decide what
topics fit your lifestyle and goals. If you want, you can chart your
progress with a food-intake tracker and exercise tracker. You’ll
also find articles and blogs related to your wellness interests and
calendars of wellness events.
All of our wellness services will continue to be FREE to active
state employees. All active state employees are encouraged to
participate; however, only the employees who choose a Wellness
Alternative Plus health plan will receive the financial incentive of a
discounted premium.
The new-and-improved OKHealth will be available to you starting
October 3rd – the first day of the Option Period for benefits
enrollment.
For more information about the exciting, new OKHealth program,
visit the OKHealth section of www.ebc.ok.gov.
Smarter, Healthier
Benefits Choices
Health Plans
Dental Plans
Vision Plans
Benefit Allowance
Sooner Save
OK Health Health
Mentoring Program State of Oklahoma
Employees Benefits Council
2012 Benefits
Enrollment Guide
Table of Contents
OKHealth . . . . . . . . . . . 1
Vision Plans . . . . . . . . . . 2
New Opt-Out Details . . . . . . . . . . . 4
Benefit Allowance . . . . . . . . 4
Plan Rates . . . . . . . . . . 5
Health Plans Comparison . . . . . 9
Dependent Eligibility . . . . . . 26
Benefits Enrollment Calculator . . . 27
Online Enrollment . . . . . . . . 27
Eligibility Reminder . . . . 27
Invisible Bracelet . . . . . . . . 28
Flexible Spending Accounts . . . . 28
Health Care Account . . . . . . 29
Dependent Care Account . . . . . 30
Mass Transportation Accounts . 30
Life, Supplemental life
& Dependent life . . . . . . . 31
Dental Plans . . . . . . . . . 32
Disability . . . . . . . . . . . 34
Employee Assistance Program . . . 34
SoonerSave . . . . . . . . . . 34
Benefits Details . . . . . . . . . 36
Glossary . . . . . . . . . . 39
of the Office of State Finance
Plan Year 2012
BENEFITS ENROLLMENT GUIDE
Active and New Employees of the State of Oklahoma
EBC 2012
2 2012 Employees Benefits Council of the Office of State Finance
vision Plans
It’s important for you to have
a good “vision” of what
combination of benefits choices
will fit you and your family
best. So this year, your benefits
office is placing an increased
emphasis on the eye-opening
benefits of a good vision plan.
Routine eye exams help keep
your vision sharp, allow eye
professionals to treat eye
infections and injuries more
effectively, and help them spot
early signs of eye conditions,
like astigmatism or glaucoma.
But the preventive advantages
don’t stop at the eyes. The
exams also help eye doctors
spot symptoms of diseases and
conditions like diabetes, high
blood pressure, osteoporosis
and brain tumors.
For Vision plan rates,
see pages 5 and 6.
Humana: If a member prefers contact lenses the plan
provides an allowance for the exam and contacts, in lieu of
all other benefits. **Contact lens benefit provides a $130
yearly allowance towards the exam and purchase of either
conventional or disposable contacts. If lenses and frames
are purchased at the same time only one $25 copay applies.
Over 23,000 frames are covered in full with in-network
providers. Exams, lenses, frame benefits provided once every
12 months. Oklahoma City LasikPlus Traditional Intralase
(bladeless) with a one year plan with insurance discount is
$695 per eye equals $1,390. Traditional Intralase (bladeless)
with a lifetime plan with insurance discount is $1,395 per eye
which equals $2,790. CustomVue Intralase (bladeless) with
a lifetime plan with insurance discount is $1,784.15 which
equals $3,568.30
PVCS: Member must select either in-network or out-of-
nework for entire plan year. In-network services are
unlimited. Out-of-network services (one eye exam, one set of
eyeglasses or contacts) are limited to once annually. A $50.00
service fee applies to all soft contact lens fittings; a $75.00
service fee applies to rigid or gas permeable contact lens
fittings; and a $150.00 service fee applies to hybrid contact
lens fittings. Simple replacements are not assessed with these
fees. Limitations/Exclusions include the following: 1) Medical
eye care, 2) Vision Therapy, 3) Nonroutine vision services
and tests, 4) Luxury frames (wholesale cost of frame is $100
or more), 5) Premium prescription lenses, and
6) non-prescription eyewear. For more information call (888)
357-6912.
United Healthcare: For either glasses or contact lenses there
is one $25 materials copay. In lieu of lenses and frames,
you may select contact lenses. Covered contact lens benefit
includes the fitting/evaluation fees, contact lenses, and up
to two follow-up visits. If covered disposable contact lenses
are chosen, up to six boxes (depending on prescription)
are included when obtained from a network provider. It
is important to note that UHC’s covered contact lenses
may vary by provider. Should you choose contact lenses
outside of the covered selection, a $150 allowance will be
Notes:
COVERED
SERVICES
In-Network Out-of-Network In-Network Out-of-Network
Eye Exams No Copay
No limit to
frequency
Plan pays
up to $40
Limit 1 exam
$10 copay
One exam for
eyeglasses or
contacts every
calendar year
Plan pays up to $35;
One exam every
calendar year
Lenses Per Pair
Member pays
wholesale cost
No limit to number
of pairs
Member pays
normal doctor Fees,
reimbursed up to
$60 for one set of
lenses & frame
annually
$25 Copay for
single/multi-focal
lenses
Plan pays up to:
Single up to $25
Bifocals up to $40
Trifocals up to $60
Lenticular up to
$100
Frames
Member pays
wholesale cost
No limit to number
of frames
Member pays
normal doctor fee
reimbursed up to
$60 for one set of
lenses and frames
annually
$25 Copay, up
to plan limits.
One frame every
calendar year
Plan pays up to $45
Contact Lenses
Member pays
wholesale cost
for annual supply of
contacts
Limit of one set
annually in lieu of
eyeglasses.
Member pays
normal doctor fees
reimbursed up to
$60
**$130 allowance
for conventional or
disposable lenses
and fitting fee in lieu
of all other benefits
every calendar year
Medically necessary,
plan pays 100%
**$130 allowance for
contacts, and fitting
fee in lieu of all
other benefits.
Medically necessary,
plan pays up to $210
Laser Vision
Correction
Discount
nationwide at
The Laser Center
(TLC)
No Benefit
Discount thru TLC,
member will pay no
more than $895 per
eye for conventional
Lasik. See notes
below on Intralase
(bladeless) options.
No Benefit
Humana
www.visioncare.com
PVCS
www.pvcs-usa.com
Lens Options
UV Coating
$11 Copay:
no limit
Member pays
normal doctor Fees
Substantial discount
$15 member cost No Benefit
Tint $11 Copay and up:
no limit
Member pays
normal doctor Fees
Substantial discount
$13 member cost No Benefit
Standard scratch
resist
$13 Copay:
no limit
Member pays
normal doctor Fees
Substantial discount
$16 member cost No Benefit
Standard
Polycarbonate
$50 Copay
and up for SV;
no limit
Member pays
normal doctor Fees
Substantial discount
$30 member cost No Benefit
Standard
Progressive
Wholesale cost,
no limit
Member pays
normal doctor Fees
Substantial discount
$82 member cost
No Benefit
Anti-Reflective $40 and up copay
No Limit
Member pays
normal doctor Fees
Substantial discount
$46 member cost
No Benefit
Oklahoma
Company
2012 Benefits Enrollment Guide 3
applied toward the fitting/evaluation fees and purchase
of contact lenses (materials copay does not apply). Toric,
gas permeable, and bifocal contact lenses are examples of
contact lenses that are outside of our covered contacts.
Necessary contacts are covered-in-full after applicable copay.
Exams, lenses, frame benefits provided once every calendar
year.
Superior: *Materials copay applies to lenses and/or frames.
Discounts for lens add-ons will be given by contracted
providers with a “DP” in their listing. Online, in-network
contact lens materials available at www.svcontacts.com.
Exams, lenses, and frames benefits provided once per
calendar year.
*Progressive Lenses (no-line bifocals) – you will pay the
difference between the retail price of the selected progressive
lens and the retail price of the lined trifocal. The difference
may also be subject to a discount.
Standard contact lens fitting applies to an existing contact
lens user who wears disposable, daily wear, or extended wear
lenses only. The Specialty contact lens fitting applies to a
new contact lens wearers and/or a member who wears toric,
gas permeable or multifocal lenses.
VSP: Exam, lenses and frame benefit provided annually. The
$25 materials copay applies to lenses or frames, but not to
both. Copays/price on premium lens options will vary. If
you choose a frame valued at more than your allowance,
you’ll save 20% on your out-of-pocket costs when you use
a VSP doctor. Contact lenses are in lieu of spectacle lenses
and frames. The $120 in-network allowance applies to the
contact lenses. With a VSP provider, the contact lens exam
(fitting and evaluation) is covered in full after a copay up to
$60. The $105 out-of-network applies to the contacts and
the contact lens exam. Your contact lens exam is performed
in addition to your routine eye exam to check for eye health
risks associated with improper wearing or fitting of contacts.
Prescription glasses - 30% off additional complete pairs of
glasses and sunglasses, including lens options, from the same
VSP doctor on the same day as your WellVision Exam. Or
get 20% off from any VSP doctor within 12 months from
your last WellVision Exam.
$10 Copay
$10 Copay then plan
pays up to
$34 - Ophthalmologist
$26 - Optometrist
$10 Copay Reimbursement
up to $40 $10 Copay $10 Copay then plan
pays up to $35
$25 Copay
Lenses are covered in
full after copay
$25 Copay then plan
pays up to
Single up to $26
Bifocals up to $39
Trifocals up to $49
Lenticular up to $78
$25 Copay
Single up to $40
Bifocals up to $60
Trifocals up to $80
Lenticular up to $80
$25 Copay applies
to lenses or frames.
Single vision, lined
bifocal and trifocal
lenses covered in full.
Average 35% discount
on lens options.
$25 Copay,
then plan pays:
Single up to $25
Bifocals up to $40
Trifocals up to $55
Lenticular up to $80
No Copay
Plan pays up to $120.
Medically necessary
contacts covered in
full. (Contact lens fit
copay: Standard $25, after
copay, covered in full.
Specialty $25, after copay,
plan pays up to $50.)
No Copay
Plan pays up to $100
All Contacts $210
Medically necessary
(Contact lens fit copay:
Standard not covered.
Specialty not covered.)
$25 Copay
On covered-in-full
qualifying lenses
(covers fitting and
evaluation fees,
contact lenses and up to
2 follow-up visits)
(See Notes)
Reimbursement up to
$150 elective contact
lenses,
$210 Medically
necessary contact
lenses
No Copay
Plan pays up to
$120 Conventional
or Disposable.
Medically necessary
contacts covered in full
with prior authorization.
No Copay
Plan pays up to
$105 Conventional
or Disposable,
$210 Medically
necessary
20%-50% Discount
off surgical fees No Benefit
Discount
15 percent off the
usual
& customary
price, 5% off
promotional price
No Benefit
15% average off
usual and customary
price or 5 percent
off the laser center’s
promotional price
No Benefit
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
UnitedHealthcare Vision
Formerly Spectera
www.myuhcvision.com
Superior
www.superiorvision.com
VSP
www.vsp.com
$25 Copay*,
then plan pays up to
$125 retail
Plan pays up to $68 $25 Copay Reimbursement
up to $45
$25 Copay, then plan
pays up to $120
$25 Copay, then plan
pays up to $45
20% discount No Benefit Covered-in-full No Benefit $14 copay No Benefit
20% discount No Benefit Covered-in-full No Benefit $13 - $15 copay No Benefit
20% discount No Benefit Covered-in-full No Benefit $15 copay No Benefit
20% discount No Benefit Available 20-40%
discount No Benefit
Covered in full for dependent
children
$25 - $30 copay for all others
No Benefit
$25 Copay,
*See notes below
Up to $49
*See notes below
Available 20-40%
discount No Benefit $50 copay No Benefit
20% discount No Benefit Available 20-40%
discount No Benefit $39 copay No Benefit
4 2012 Employees Benefits Council of the Office of State Finance
New Login box
Your entry point for
Online Enrollment in the
Benefits Administration
System (BAS) now
looks a little different
(see image at right).
It is in the upper right
corner of the EBC
home page,
www.ebc.ok.gov.
Notice the “Go To”
line, followed by a
drop-down menu.
That is where you
will choose either the new OKHealth Portal or the
Benefits Administration System, which is where you’ll
find Online Enrollment. Your User ID is your six-digit
Employee ID. If you don’t know your password, either
select “Forgot Your Password” or simply select LOGIN
and you will be directed to a screen where you can
update your password.
New Opt-out details
With the approval of House Bill 1062 in May 2011,
state employees were given the right to opt out of state
benefits. Specifically,
“Any active employee eligible to participate or who
is a participant may opt out of the state’s basic
plan as outlined in Sections 1370 and 1371 of Title
74 of the Oklahoma Statutes, provided that the
participant is currently covered by a separate group
health insurance plan. Any active employee eligible
to participate or who is a participant opting out of
coverage pursuant to this section shall provide proof
of the separate health insurance plan participation
and sign an affidavit attesting that the participant
is currently covered and does not require state-provided
health insurance each plan year. Any
active employee opting out of coverage pursuant to
this section shall receive One Hundred Fifty Dollars
($150.00) in lieu of the flexible benefit amount the
employee would be otherwise eligible to receive.”
As the new law spells out, you may opt out ONLY if
you are currently covered by a separate group health
insurance plan. In addition, you must provide proof of
the separate health insurance plan participation and
sign an affidavit before the opt-out will be approved.
You will need to fill out a new form which is available
through your Benefits Coordinator.
The “basic plan” described in the new law consists of
the following: health, dental, basic life and disability
insurance. If you opt out, you are no longer eligible for
any of those coverages through the State. Because
Basic Life insurance is a prerequisite for the optional
Supplemental Life and Dependent Life, those are
eliminated, as well. However, state employees who opt
out can still take advantage of vision insurance offered
by the State, as well as Flexible Spending Accounts
(FSAs).
If you are considering opting out, please understand
you are forfeiting the normal benefit allowance provided
by your agency. In lieu of that benefit allowance, you will
get $150 per month from your agency. That $150 can
be used to pay for vision coverage, FSA contributions,
and/or added to your net pay as taxable income.
Retired Military
State employees who have retired from military service
and have federal TRICARE insurance benefits can also
opt out of the state’s basic plan. Those individuals
will get no coverage for health, dental, life, disability,
supplemental life or dependent life insurance. In lieu of
the normal benefit allowance, TRICARE opt-outs will
receive $150 per month from their agencies. They can
still elect vision coverage as well as flexible spending
account participation. A copy of the participant’s military
service card will be requested as proof of TRICARE
coverage. Employees who go this route must opt out
each year because the election does not roll over.
In response to Senate Bill 623, which also became
law in 2011, your Benefits Office is making a TRICARE
supplement available to military retirees in 2012. See
page 5 for monthly rates and page 6 for biweekly rates.
Benefit Allowance
Your Benefit Allowance Helps
Cover Your Costs The State provides
a Benefit Allowance to help you pay
for insurance premiums that would
otherwise come out of your own
pocket. An estimated 90 percent of
state employees and their families will continue having
100 percent of benefits paid with these dollars. Per
state law, it is calculated using the average of the
highest-cost health plans, the average of the dental
plan premiums, plus the premiums for basic life and
disability. As rates increase, so does your Benefit
Allowance. For employees electing to cover dependents
on health, an allowance is provided to cover 75 percent
of the average of all high option premium dependent
costs.
New login box
2012 Benefits Enrollment Guide 5
Health
CommunityCare: Standard Plan 803.22 1,951.80 2,353.40 2,594.36 1,204.82 1,445.78
CommunityCare: Alternative Plan 553.96 1,346.10 1,623.08 1,789.26 830.94 997.12
CommunityCare: Wellness Alternative Plus 528.96 1,321.10 1,598.08 1,764.26 805.94 972.12
GlobalHealth: Standard Plan 402.84 1,063.56 1,275.83 1,402.00 615.11 741.28
GlobalHealth: Alternative Plan 366.24 966.92 1,159.92 1,274.62 559.24 673.94
GlobalHealth: Wellness Alternative Plus 341.24 941.92 1,134.92 1,249.62 534.24 648.94
United Healthcare Standard Plan 768.80 1,874.16 2,258.28 2,488.88 1,152.92 1,383.52
United Healthcare Alternative Plan 530.20 1,292.52 1,557.42 1,716.46 795.10 954.14
United Healthcare: Wellness Alternative Plus 505.20 1,267.52 1,532.42 1,691.46 770.10 929.14
HealthChoice High 449.48 1,117.58 1,345.78 1,469.66 677.68 801.56
HealthChoice High Alternative 449.48 1,117.58 1,345.78 1,469.66 677.68 801.56
HealthChoice Basic 391.64 963.48 1,165.30 1,274.28 593.46 702.44
HealthChoice Basic Alternative 391.64 963.48 1,165.30 1,274.28 593.46 702.44
HealthChoice USA 688.82 1,377.64 1,603.86 1,726.50 915.04 1,037.68
HealthChoice S-Account 382.56 925.08 1,115.26 1,216.98 572.74 674.46
Tricare Supplement 59.00 118.00 177.00 218.00 118.00 159.00
Dental
Assurant Heritage Plus Dental Plan 11.74 20.60 28.20 35.80 19.34 26.94
Assurant Freedom Preferred Dental Plan 28.83 57.50 79.00 115.30 50.33 86.63
Assurant Heritage Secure Dental Plan 7.20 13.18 18.38 23.56 12.40 17.58
CIGNA Dental 9.26 15.32 22.40 30.64 16.34 24.58
Delta Dental PPO 33.64 67.26 96.52 141.30 62.90 107.68
Delta’s Choice PPO Choice 15.06 49.24 83.68 132.84 49.50 98.66
Delta Dental Premier 38.36 76.72 110.10 161.18 71.74 122.82
HealthChoice Dental 30.20 60.40 85.58 125.72 55.38 95.52
Vision
Humana 6.76 11.82 15.39 16.28 10.33 11.22
Primary Vision Care Services 9.25 17.25 25.75 28.00 17.75 20.00
United HealthCare Vision 8.18 13.97 18.56 20.95 12.77 15.16
Superior Vision Services 7.14 14.24 20.96 28.04 13.86 20.94
Vision Service Plan 8.76 14.63 20.25 27.27 14.38 21.40
Life Insurance Options
Life 4.00 Supplemental Life First Unit 4.00
Disability 9.10
Dependent Life Supplemental Life Age Rated (Per $20,000)
Low Option 2.60 Age
Standard Option 4.32 <30 0.60
Premier Option 8.64 30-34 0.60
35-39 0.80
40-44 1.20
45-49 2.00
50-54 3.40
55-59 5.40
60-64 6.20
65-69 10.20
70-74 17.40
75+ 27.00
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
2012 MONTHLY PLAN RATES
Monthly Benefit Allowance
Employee 640.98
Plus Child 870.89
Plus Children 1,006.19
Plus Spouse 1,312.75
Plus Spouse & 1 Child 1,542.66
Plus Spouse & Children 1,677.96
Monthly
Monthly
6 2012 Employees Benefits Council of the Office of State Finance
Health
CommunityCare: Standard Plan 370.72 900.83 1,086.18 1,197.40 556.07 667.29
CommunityCare: Alternative Plan 255.67 621.27 749.11 825.81 383.51 460.21
CommunityCare: Wellness Alternative Plus 244.14 609.74 737.58 814.28 371.98 448.68
GlobalHealth: Standard Plan 185.93 490.88 588.85 647.08 283.90 342.13
GlobalHealth: Alternative Plan 169.03 446.27 535.35 588.29 258.11 311.05
GlobalHealth: Wellness Alternative Plus 157.50 434.74 523.82 576.76 246.58 299.52
United Healthcare Standard Plan 354.83 865.00 1,042.29 1,148.72 532.12 638.55
United Healthcare Alternative Plan 244.71 596.55 718.81 792.21 366.97 440.37
United Healthcare: Wellness Alternative Plus 233.17 585.01 707.27 780.67 355.43 428.83
HealthChoice High 207.45 515.80 621.12 678.30 312.77 369.95
HealthChoice High Alternative 207.45 515.80 621.12 678.30 312.77 369.95
HealthChoice Basic 180.76 444.69 537.84 588.14 273.91 324.21
HealthChoice Basic Alternative 180.76 444.69 537.84 588.14 273.91 324.21
HealthChoice USA 317.92 635.84 740.25 796.85 422.33 478.93
HealthChoice S-Account 176.57 426.96 514.74 561.68 264.35 311.29
Tricare Supplement 27.23 54.46 81.69 100.61 54.46 73.38
Dental
Assurant Heritage Plus Dental Plan 5.42 9.51 13.02 16.53 8.93 12.44
Assurant Freedom Preferred Dental Plan 13.31 26.54 36.46 53.22 23.23 39.99
Assurant Heritage Secure Dental Plan 3.32 6.08 8.48 10.87 5.72 8.11
CIGNA Dental 4.27 7.07 10.34 14.14 7.54 11.34
Delta Dental PPO 15.53 31.05 44.55 65.22 29.03 49.70
Delta’s Choice PPO Choice 6.95 22.73 38.63 61.31 22.85 45.53
Delta Dental Premier 17.70 35.40 50.81 74.38 33.11 56.68
HealthChoice Dental 13.94 27.88 39.50 58.03 25.56 44.09
Vision
Humana 3.12 5.46 7.11 7.52 4.77 5.18
Primary Vision Care Services 4.27 7.96 11.88 12.92 8.19 9.23
United HealthCare Vision 3.78 6.45 8.57 9.67 5.90 7.00
Superior Vision Services 3.30 6.58 9.68 12.95 6.40 9.67
Vision Service Plan 4.04 6.75 9.34 12.58 6.63 9.87
Life Insurance Options
Life 1.85 Supplemental Life First Unit 1.85
Disability 4.20
Dependent Life Supplemental Life Age Rated (Per $20,000)
Low Option 1.20 Age
Standard Option 1.99 <30 0.28
Premier Option 3.99 30-34 0.28
35-39 0.37
40-44 0.55
45-49 0.92
50-54 1.57
55-59 2.49
60-64 2.86
65-69 4.71
70-74 8.03
75+ 12.46
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
2012 BIWEEKLY PLAN RATES
Biweekly Benefit Allowance
Employee 295.84
Plus Child 401.95
Plus Children 464.40
Plus Spouse 605.89
Plus Spouse & 1 Child 712.00
Plus Spouse & Children 774.45
BIWEEKly
BIWEEKly
2012 Benefits Enrollment Guide 7
Premium Conversion
Do You Want to Save on Your Taxes?
Premium Conversion is an optional, IRS-approved
election chosen by more than
97 percent of state employees, allowing
you to save by paying NO TAX on your
eligible insurance premiums. By paying insurance
premiums for health, dental, vision, flexible spending
accounts and a portion of supplemental life pre-tax, you
have more take-home pay than you would if you paid
the same premiums with after-tax dollars.
The premium conversion option is automatic. You will
be enrolled in premium conversion unless you elect to
opt out. You can opt out of premium conversion in two
ways.
• Select “No” to premium conversion during online
enrollment
• Check the “No” box under the Premium Conversion
section of the paper enrollment form
If you have questions about your premium conversion
options, be sure to ask your Benefits Coordinator.
3 Yes = tax savings!
New Health plans with
discounts!
For the first time, you can get
a discounted premium or lower
deductible on state health insurance!
Now that we have your attention…
Your Benefits Office proudly introduces the “Wellness
Alternative Plus” plans. They are HMO Alternative
plans that cost $25 less per month. As long as you
live or work in a zip code that is serviced by one of the
state’s three HMOs, the only thing you have to do to
get the discounted premium is complete a Health Risk
Assessment (HRA). You’ll find it in the OKHealth section
of www.ebc.ok.gov. It only takes a few minutes to fill
out, and in return, you’ll save $300 during 2012. The
discount is available to all state employees, including
current and former OKHealth participants; however, a
new HRA is required.
You have until November 10th to complete the HRA.
If you choose a Wellness Alternative Plus plan, but
don’t complete the HRA by November 10th, you will
be defaulted into that company’s Alternative plan,
which has a higher rate.
Wellness Alternative Plus plans are offered by each of
the available HMOs: CommunityCare, GlobalHealth
and UnitedHealthcare. It is important to note: the
discounted rates for the new plans were not attained by
increasing premiums on other plans. Best-and-final-offer
rates for the HMO Standard and Alternative plans did
not change after the new plans were requested. Your
Benefits Office negotiated the $25/month discounts by
emphasizing that wellness program participants typically
have lower utilization of health care and are, therefore,
less expensive to insure. The private-sector health plans
agreed and support the initiative to improve the overall
health of state employees. Check your zip code by
going to the EBC web site, www.ebc.ok.gov, go to the
Benefits section and select “Provider Directory.” Select
your zip code from the drop-down list. If it’s not on the
list, please check with your Benefits Coordinators to
check HMO availability in your area.
Most HealthChoice members have opportunities to
save, as well. State employees who don’t smoke or
use other tobacco products will continue to have
a HealthChoice High annual deductible of $500
(individual) or $1,500 (family). Otherwise, the calendar
year deductibles will be $750 or $2,250. In addition,
HealthChoice members can complete the H.E.L.P.
Health Risk Assessment as well as the biometric
requirements and receive $100. Look for the HRA
link on the home page of www.sib.ok.gov or www.
healthchoiceok.com.
HealthChoice Health Plans
• Each year, tobacco use costs the HealthChoice
health plans and their members approximately $52
million. Because these costs affect the premiums of
all health plan members, HealthChoice is encouraging
members to stay or become tobacco free by freezing
the deductible and out-of-pocket limits of the
HealthChoice High and Basic Plans at 2011 amounts
for non-tobacco users. The HealthChoice High
Alternative and HealthChoice Basic Alternative Plans
are being introduced for tobacco users. The individual
deductibles and out-of-pocket limits for these two
plans are $250 higher than the High and Basic Plans.
To enroll or remain enrolled in the HealthChoice High
or Basic Plan for Plan Year 2012, you must attest that
you and your covered dependents are tobacco-free
by completing the HealthChoice High and Basic Plans
Tobacco-Free Attestation for Plan Year 2012 by October
28, 2011. The attestation is available to you:
• Online at www.sib.ok.gov or
www.healthchoiceok.com
• From your Benefits Coordinator
• By calling HealthChoice Member Services at
1-405-717-8780 or toll-free 1-800-752-9475.
TDD users call 1-405-949-2281 or toll-free
1-866-447-0436.
If you cannot complete the tobacco-free attestation
because you and/or your covered dependents are not
tobacco-free, you can still qualify for the HealthChoice
High or HealthChoice Basic plan if you can show proof
of an attempt to quit using tobacco or provide a letter
from your doctor. To qualify for the tobacco-free plans,
you must provide one of the following:
(continued on page 8)
8 2012 Employees Benefits Council of the Office of State Finance
• A letter indicating you and/or your covered
dependents have enrolled in the quit tobacco program
available through the Oklahoma Tobacco Settlement
Endowment Trust (TSET) and Alere Wellbeing within
the previous 90 days.
• A letter indicating you and/or your covered
dependents have completed the quit tobacco
program available through the Oklahoma Tobacco
Settlement Endowment Trust (TSET) and Alere
Wellbeing within the previous 90 days.
• A letter from your doctor indicating it is not medically
advisable for you or your covered dependents to quit
tobacco.
The letter from TSET or your doctor must be provided
to HealthChoice at 3545 N.W. 58 Street, Suite 110,
Oklahoma City, OK 73112 by October 28, 2011. If you
do not or cannot complete the tobacco-free attestation
or provide one of the letters described previously,
you and your covered dependents will be enrolled
in the new HealthChoice High Alternative Plan or
HealthChoice Basic Alternative Plan.
HealthChoice High, High Alternative, Basic, Basic
Alternative, S-Account, and USA Plans
• No limit on visits and treatment days for mental health
and substance abuse, certification required.
• Non-Network emergency room visits will be covered
at the Network benefit level; however, you can still
be billed for non-covered services and amounts over
Allowed Charges.
• Preventive Procedures Covered at 100% of
Allowed Charges. As an enhanced benefit for
HealthChoice members, preventive procedures and
many other services will be covered at 100% of
Allowed Charges with no out-of-pocket costs when
using a Network Provider. This means no-cost access
to such services as:
• Blood pressure, diabetes, and cholesterol
tests
• Breast, cervical, prostate, and colorectal
cancer screenings
• Osteoporosis screening
• Counseling from your health care provider
on topics including quitting tobacco, losing
weight, eating healthy, treating depression,
and reducing alcohol use
• Prescription tobacco cessation products
• Vaccines for children and adults
• Flu and pneumonia shots
• Screening for obesity and counseling from
your doctor and other health professionals
to promote sustained weight loss, including
dietary counseling from your doctor
• Screening for conditions that can harm
pregnant women or their babies, including iron
deficiency, hepatitis B, a pregnancy related
immune condition called Rh incompatibility,
and a bacterial infection called bacteriuria
• Special pregnancy-tailored counseling from a
doctor to help pregnant women quit smoking
and avoid alcohol use
• Counseling to support breast-feeding and help
nursing mothers
See the HealthChoice website at www.sib.ok.gov or
www.healthchoiceok.com for more details.
HealthChoice High, High Alternative, and USA Plans
• HealthChoice is implementing a family out-of-pocket
limit for the HealthChoice High, High Alternative and
USA Plans. The family out-of-pocket limit for the High
and USA Plans will be $8,400 when using a Network
Provider and $9,900 when using a non-Network
Provider. The family out-of-pocket limit for the High
Alternative Plan will be $9,150 when using a Network
Provider and $10,650 when using a non-Network
provider.
HealthChoice S-Account Plan
• The out-of-pocket limits are being lowered to
$3,000/individual and $6,000/family.
• Proof of a Health Savings Account (HSA) is not
required to enroll.
• HealthChoice has contracted with American Fidelity
Health Services Administration to make establishing
and keeping a Health Savings Account easier and
more convenient for S-Account members. See the
Health Savings Accounts information page in the back
pocket of this guide.
HealthChoice Pharmacy Benefit
• Two 90-day courses of prescription tobacco cessation
products will be covered at 100% with no cost to
members.
• HealthChoice is introducing a mail order pharmacy
benefit and changing the quantity of medication
members can get per copay. A 30-day supply of
medication will be covered when purchased at a
retail pharmacy for one copay. A 90-day supply of
maintenance medication will be covered for one
copay when purchased through Medco’s mail order
service or one of the Network Retail Maintenance
Pharmacies. See the Health Plan Comparison for
copay amounts.
2012 Benefits Enrollment Guide 9
2012
Health
Plans
Comparison
Chart
Active and New Employees
of the State of Oklahoma
10 2012 Employees Benefits Council of the Office of State Finance
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
Choice of Provider
Calendar Year Deductible
Annual Out-of-Pocket
Maximum
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP
on Enrollment Form)
PCP referral & HMO
authorization required for
some care received
outside PCP office.
None
Individual: $2,500
Family: $5,000
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP on
Enrollment Form)
However, no referral
for your contracted
specialist when the
specialist is in
UnitedHealthcare’s
SignatureValue HMO
network (referral
required for behavioral
health and chiropractic
providers)
None
Individual: $2,500
Family: $5,000
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP
on Enrollment Form)
Members may
self-refer to most
specialists for initial
visit.
None
Individual: $3,000
Family: $6,000
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP
on Enrollment Form)
PCP referral & HMO
authorization required
for all care received
outside PCP office. You
may self-refer to an
in-network OB/GYN.
For children, you may
designate a pediatrician
as the primary care
provider.
None
Individual: $3,000
Family: $5,000
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 11
Choice of Network Provider for
medically necessary services
$30 Physician
$50 Specialist
Physicians include;
General Practitioners
Internal Medicine Physicians
OB/GYNs
Pediatricians
Physician Assistants
Nurse Practioners
High
Individual: $500
Family: $1,500
High Alternative
Individual: $750
Family: $2,250
See Emergency
Health Care for additional per
service deductible.
High
Individual: $2,800
Family: $8,400
(includes deductible)
High Alternative
Individual: $3,050
Family: $9,150
(includes deductible)
Non-covered services,
copays & ER deductible
do not apply
Choice of any Provider,
Allowed Charges for medically
necessary services. Member
responsible for amount that
exceeds the Allowed Charges
when using a non-Network
provider and all ineligible
expenses.
High
Individual: $500
Family: $1,500 plus $300
per confinement hospital
deductible.
High Alternative
Individual: $750
Family: $2,250 plus $300
per confinement hospital
deductible.
See Emergency Health
Care and Hospital Inpatient
for additional per service
deductible.
High
Individual: $3,300
Family: $9,900
(includes deductible)
High Alternative
Individual: $3,550
Family: $10,650
(includes deductible)
plus Member is
responsible for
amount that exceeds
the Allowed Charges,
inpatient deductible, ER
deductible & charges over
maximum benefit limitations
Choice of any Provider,
Allowed Charges for
medically necessary
services. Member
responsible for amount
that exceeds the Allowed
Charges when using a non-
Network provider and all
ineligible expenses.
Basic
Individual: $500
Family: $1,500 Deductible
applies after Plan pays first
$500 of Allowed Charges.
Basic Alternative
Individual: $750
Family: $1,500
Deductible applies after
Plan pays first $250 of
Allowed Charges. Plan
offers same benefits and
unlimited lifetime maximum
on eligible health and
pharmacy benefits as the
HealthChoice High Plan.
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Choice of Provider for
medically necessary
services
Individual: $1,500
Family: $3,000
The combined medical
and pharmacy deductible
must be met before
benefits are paid.
Individual: $3,000
Family: $6,000
Non-Network charges do
not apply.
HealthChoice
High & High Alternative
Network
A reduced benefit level and additional
out-of-pocket costs apply when using a
non-Network provider
HealthChoice
High & High Alternative
Non-Network
A reduced benefit level and additional
out-of-pocket costs apply when using a
non-Network provider
HealthChoice
Basic &
Basic Alternative
Additional out-of-pocket costs apply
when using a non-Network provider
HealthChoice
S-Account
Network*
A reduced benefit level and additional
out-of-pocket costs apply when using
a non-Network provider
12 2012 Employees Benefits Council of the Office of State Finance
Office Visits
(Professional Services)
Prescription Drugs
Copayments
$30 PCP
$40 Specialist per visit
$5/$30/$60
30 day supply
Selected medications
may have restricted
quantities.
Copays
$35 PCP
$50 Specialist
$5 copay for
formulary generic
drug
$30 copay for
formulary brand
name drug
$60 non-formulary
generic and brand
drug
The lesser of 30-day
supply or 100 units;
certain medications
have restricted
quantities
******************
Contraceptive Drugs:
$5 copay for
formulary generic
drug
$30 copay for
formulary brand
name drug
$60 non-formulary
generic and brand
drug
The lesser of 30-day
supply or 100 units;
certain medications
have restricted
quantities
Copays
$35 PCP copay per
visit
$50 Specialist copay
per visit
Up to $0 select generic
formulary
Up to $10 generic
formulary
Up to $40 brand
formulary
(when no generic is
available)
Up to $65 brand
formulary
(when generic is
available)
Up to $65 non
formulary
30-day supply
Selected medications
may have restricted
quantities.
Convenience Mail
Order Pharmacy
Up to 90 day supply
for 3 copays
Copayments
$25 PCP
$50 Specialist
$10/$50/$75
Includes a 1 month
supply
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 13
$30 Physician copay; $50
Specialist copay per office visit;
for other professional services,
the calendar year deductible
applies first; member pays 20%
of Allowed Charges
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum of
$10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands - Cost
of medication is up to $60, or a
maximum of $120
Mail Delivery and
Retail Maintenance
Pharmacies – 90 day supply:
Preferred Generic – Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60.
Non-Preferred Brand - Cost
of medication up to $60 or a
maximum copay of $120.
Specialty Medication Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per 30-
day supply
Brand/Generic difference:
Member is responsible for the
difference in the brand and
generic if a brand is purchased
when a generic is available. For
more details visit
www.healthchoiceok.com or
www.sib.ok.gov
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount that exceeds
the Allowed Charges and all
ineligible expenses
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum
of $10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands - Cost
of medication is up to $60, or a
maximum of $120
Mail Delivery and Retail
Maintenance Pharmacies – 90
day supply:
Preferred Generic –Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60.
Non-Preferred Brand - Cost
of medication up to $60 or a
maximum copay of $120.
Specialty Medication Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per 30-
day supply
Brand/Generic difference:
Member is responsible for the
difference in the brand and
generic if a brand is purchased
when a generic is available. For
more details visit
www.healthchoiceok.com or
www.sib.ok.gov
Once a Member spends
$5,500/$5,750 out-of pocket,
the Basic Plan will pay 100%
of all other Allowed Charges
for that Plan Year. Family
deductible is $1,000/$1,500
w/a maximum annual
family out-of-pocket of
$11,000/$11,500
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum
of $10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands -
Cost of medication is up to
$60, or a maximum of $120
Mail Delivery and Retail
Maintenance Pharmacies –
90 day supply:
Preferred Generic –Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60. Non-
Preferred Brand - Cost of
medication up to $60 or a
maximum copay of $120.
Specialty Medication
Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per
30-day supply
Brand/Generic difference:
Member is responsible for
the difference in the brand
and generic if a brand is
purchased when a generic
is available. For more details
visit
www.healthchoiceok.com or
www.sib.ok.gov
After the calendar year
deductible, $50 copay
After the $1,500 individual
or $3,000 family deductible
has been met, the pharmacy
benefits are:
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum
of $10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands -
Cost of medication is up to
$60, or a maximum of $120
Mail Delivery and Retail
Maintenance Pharmacies –
90 day supply:
Preferred Generic –Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60.
Non-Preferred Brand - Cost
of medication up to $60 or a
maximum copay of $120.
Specialty Medication
Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per
30-day supply
Brand/Generic difference:
Member is responsible for
the difference in the brand
and generic if a brand is
purchased when a generic
is available. For more details
visit
www.healthchoiceok.com or
www.sib.ok.gov
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
14 2012 Employees Benefits Council of the Office of State Finance
No charge one time
per plan year for
PCP visits, biometric
measurements and
lab work as specified
by OK Health
Program. If any other
services are provided
during PCP office
visit, member will be
charged an office
copay and other
appropriate charges
$500 copay per
admission
(prior authorization
from PCP required)
$300 copay per visit
outpatient surgical
facility
$200 per visit copay
(waived if admitted)
$50 copay per visit
(prior authorization
required)
No charge one time per
plan year for PCP visits,
biometric measurements
and lab work as
specified by OK Health
Program
$250 copayment per
inpatient day
$750 max. per
admission
Precertification from
PCP required
$250 copayment per
visit
As authorized by PCP
$150 per visit
copayment
(waived if admitted)
$25 PCP/$50 all other
providers
NOTE: Must use in-network
facilities.
No charge one time
per plan year for
PCP visits biometric
measurements and
lab work related
to the OK Health
Program.
If any other services
are provided during
this PCP office visit,
member will be
charged an Office
Visit copay.
$1,000 Copay per
admit
$500 copay per
Outpatient Surgery
visit
$200 copay per visit
(waived if admitted
as an
inpatient from
emergency room)
$50 copay per visit
No charge one time per
plan year for PCP visits,
biometric measurements
and lab work as
specified by OK Health
Program. If any other
services are provided
during this PCP office
visit, member will
be charged office
visit copay and other
appropriate charges.
$350 per admission
$250 per visit
$150 per visit
(waived if admitted)
$40 per visit
OKHealth Program
(Only for State employees
participating in OKHealth
Program, dependents do
not qualify.)
Hospital Inpatient
Hospital Outpatient
Emergency Health Care
After Hours Urgent Care
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 15
One free initial doctor’s office
visit related to OK Health
Program requirements.
One free fasting lipid
(Cholesterol/
triglycerides) profile
One fasting glucose (sugar) test
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar year
deductible.
Certification required
for certain outpatient
surgeries
Member pays 20% of Allowed
Charges after the calendar year
deductible.
$100 ER deductible; waived if
hospitalized
Member pays 20% of
Allowed Charges after the
calendar year deductible
Not covered for
non-Network
Member pays 50% of
Allowed Charges after
the calendar year deductible
and $300 per confinement
hospital deductible, plus
amount that exceeds the
Allowed Charges and
all ineligible expenses.
Certification
required
Member pays 50% of
Allowed Charges after the
calendar year deductible,
plus amount that exceeds
the Allowed Charges and
all ineligible expenses.
Certification
required for certain
outpatient surgeries
Member pays 20% of
Allowed Charges after the
calendar year deductible,
plus amount that exceeds the
allowed charges.
$100 ER deductible; waived if
hospitalized
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
One free initial Network
provider’s office visit related
to OK Health Program
requirements.
One free fasting lipid
(Cholesterol/
triglycerides) profile, one
fasting glucose (sugar) test
HealthChoice Basic plan
offers the same benefits
as the HealthChoice High
(Network) Plan
Using Network providers will
maximize your benefits.
Certification required
The $100 ER deductible
does not apply to the Basic
and Basic Alternative Plans
Basic Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
One free initial doctor’s
office visit related to
OK Health Program
requirements.
One free fasting lipid
(Cholesterol/
triglycerides) profile
One fasting glucose (sugar)
test
Member pays 20% of
Allowed Charges after
the calendar year deductible
and $300 per confinement
hospital deductible when
using a non-Network
provider plus amount
that exceeds the Allowed
Charges and all ineligible
expenses
Certification required
Member pays 20% of
Allowed Charges
after the calendar year
deductible.
Certification required for
certain outpatient surgeries
Member pays 20%
of Allowed Charges
after the calendar year
deductible.$100 ER
deductible; waived if
hospitalized
Member pays 20% of
Allowed Charges after the
calendar year deductible
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
16 2012 Employees Benefits Council of the Office of State Finance
Diagnostic X-ray and Lab
Allergy Treatment And
Testing
Well-child Care
Immunizations
Maternity
No additional
copayment for
Laboratory services or
Outpatient Radiology
$150 copayment per
scan for MRI, CT, MRA
and PET Scan
$30 per visit to PCP
$40 per visit to
Specialist
$30 for Allergy Serum
and shots, including (6)
six week supply Antigen
and administration
No Charge
No Charge (Ages birth
– 18)
No Charge (Ages 19 and
over)
$30 for initial visit
$350 per admission
No additional copay for
Laboratory services or
Outpatient Radiology.
$200 copay per scan
for MRI, CT, MRA and
PET Scan
$35 copay per visit to
PCP
$50 copay per visit to
Specialist
$30 copay for Allergy
Serum (six week
supply - including
shots)
No copay
No copay for childhood
immunizations up to 18
No copay for
medically necessary
immunizations 19 and
over
$35 copay for initial visit
only (includes prenatal
and postnatal care)
No copay for Prenatal
Classes
Amniocentesis (medically
necessary; outpatient
surgical facility copay
may apply)
$500 per admission
No additional
copayment for
Laboratory services or
Outpatient Radiology
$250 copayment per
scan for MRI, CT, MRA
and PET Scan
$25 PCP /$50 Specialist
$30 copayment per
6 weeks antigen and
shots
No Copayment up to
age 21
No copayment
Office copayments may
apply
$25 physician services
copayment for initial
visit only
$250 copayment per
day hospital admission
$750 max. per
admission
Standard Laboratory
and Radiology: $0
copay
Specialized scanning
and imaging (MRI,
MRA, PET, CAT,
Nuclear Scans): $200
copay per scan
$35 PCP
$50 Specialist
$35 Serum and shots
including a six
(6) week supply
of antigen and
administration
No copay
No copay (if no other
service is rendered)
In accordance with
the US Preventive
Services Task Force
and other health
organizations required
guidelines.
$35 PCP
$50 Specialist. copay
for initial visit once
diagnosis of
pregnancy
is confirmed;
$1,000 copay
per admit for
Hospitalization
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 17
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Limit: Battery of 60 tests
every 24 months
$0 copay for preventive well
baby exam
Well-baby and adult
immunizations covered
at 100%, $50 copay per
specialist office visit.
Administration charge may
apply
$30 Physician
$50 Specialist
Physicians include; General
Practitioners, Internal
Medicine Physicians,
OB/GYN, Pediatricians,
Physicians Assistants, Nurse
Practioners
Member pays 20% of
Allowed Charges after the
calendar
year deductible
Includes one postpartum
home visit (must meet
criteria)
Also see Hospital
Inpatient Benefits
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount that exceeds
the Allowed Charges and all
ineligible expenses
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount that exceeds
the Allowed Charges and all
ineligible expenses
Limit: Battery of 60
tests every 24 months
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
Member pays 50% of Allowed
Charges after the calendar
year deductible and $300
per confinement hospital
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Includes one postpartum home
visit (must meet criteria) Also
see Hospital
Inpatient Benefits
Basic Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Limit: Battery of 60 tests
every 24 months
$0 Copay for preventative
well-baby exam
Well-baby & Adult
immunizations covered at
100%
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of
Allowed Charges after the
calendar year deductible
Limit: Battery of 60 tests
every 24 months
$0 copay for preventive well
baby exam
Well-baby and adult
immunizations covered at
100%. Office visit is subject
to $50 copay. Administration
charge is subject to
deductible and coinsurance
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Includes one postpartum
home visit (must meet
criteria)
Also see Hospital
Inpatient Benefits
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
Contraceptive Services
Contraceptive Drugs
Infertility Services
Mental Health Inpatient
Mental Health Outpatient
Including Gambling
Addiction
$30 PCP
$40 Specialist
per visit for consultation
$30 PCP/$40 Specialist
for surgical procedure
Tier 1: $ 5
Tier 2: $30
Tier 3: $60
30 day supply
Selected medications
may have
restricted quantities.
One copay per
injectable contraceptive
25% of cost + office
visit copayment –
includes diagnosis
and some treatment
including drug treatment
$30 PCP/$40 Specialist
$350 Inpatient
No limit on treatment
days
$30 PCP
No limits on visits
$35 PCP/$50
Specialist
copay per visit for
consultation
$35 PCP/$50
Specialist copay for
surgical procedure (in
office)
See Prescription Drug
Benefits
Up to $0 select generic
formulary
Up to $10 generic
formulary
Up to $40 brand
formulary (when no
generic is available)
Up to $65 brand
formulary (when generic
is available)
Up to $65 non formulary
30-day supply
Selected medications
may have restricted
quantities. One
copay per injectable
contraceptive.
$35 PCP copay per
visit
$50 Specialist copay
per visit. Office
visit copays apply.
Infertility Services
50% Copay. Infertility
Medications (require
prior authorization)
are subject to a 50%
copay
$500 copay per
admission (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$35 PCP copay per
visit
$50 Specialist copay
per visit (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$50 copayment for
services performed in
office setting
Covered under
prescription drug benefit
Tier 1: $4/$10
Tier 2: $50
Tier 3: $75
50% coinsurance,
office visit copayments
apply
$250 per inpatient day
copayment
($750 max. per
admission)
Must be preauthorized
$25 copayment per visit
Must be preauthorized
Consultation, $35
PCP copay
$50 Specialist copay
$35PCP/$50
Specialist
Surgical Procedure
If Outpatient surgery
$500 copay
Please refer to
prescription drug
benefit; $50 copay
for Depo-Provera
Injection
25% of Total Charges
(Basic Services)
25% cost plus copay
$35 PCP
$50 Specialist
$1,000 copay per
admission
$35 PCP
18 2012 Employees Benefits Council of the Office of State Finance
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
Member pays 20% of
Allowed Charges after the
calendar year deductible
See Prescription Drugs.
Member pays 20% of
Allowed Charges after the
calendar year deductible
Benefits available for diagnosis
and some treatment.
See exclusions in member
materials
Member pays 20% of
Allowed Charges after the
calendar year deductible
Certification required
Member pays 20% of Allowed
Charges after calendar
year deductible. Requires
certification after 15 visits or
penalty will apply.
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
See Prescription Drugs.
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds Allowed Charges and
all ineligible expenses. Benefits
available for diagnosis and some
treatment. See exclusions in
member materials.
Member pays 50% of
Allowed Charges after the
calendar year deductible plus
$300 per confinement deductible,
plus amount that exceeds
Allowed Charges and all ineligible
expenses. Certification required
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Requires certification after 15
visits or penalty will apply.
See Prescription Drugs
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Member pays 20% of Allowed
Charges after the calendar
year deductible
After the $1,500 individual
or $3,000 family deductible
has been met, all Pharmacy
copays apply. See
Prescription Drugs.
Member pays 20% of Allowed
Charges after the calendar
year deductible
Benefits available for
diagnosis and some
treatment.
See exclusions in member
materials
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar
year deductible. Requires
certification after 15 visits or
penalty will apply.
2012 Benefits Enrollment Guide 19
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
20 2012 Employees Benefits Council of the Office of State Finance
Substance Abuse
Inpatient
Substance Abuse
Outpatient
Hearing Screening
Hearing Aids
Physical, Occupational,
or Speech Therapy
$350 Inpatient
No limit on treatment
days
$30 PCP
$40 Specialist
No limit on visits
No charge ages 0 to 21
Hearing Screening Adult
One (1) visit per year
$30
Not covered except for
children up to 18 years
of age: audiological
services and hearing
aids are covered
(as durable medical
equipment)
Limited 1 hearing
aid per ear every 48
months.
No Charge for Inpatient
care
(limited to sixty (60)
treatment days per
course of therapy).
Outpatient is $30
PCP/$40 Specialist
$500 copay per
admission (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$35 copay per visit
PCP
$50 copay per visit
specialist (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$0 copay per
visit(covered under
preventive care
services and limited to
one per year)
20% copay for children
up to age 18.
Coverage shall only
apply to hearing aids
that are prescribed,
filled and dispensed by
a licensed audiologist,
and may limit the
hearing aid benefit
payable for each
hearing-impaired ear
to every forty-eight
(48) months; provided,
however, such coverage
may provide for up
to four (4) additional
ear molds per year for
children up to two (2)
years of age.
No copay for Inpatient
Rehabilitation
$50 copay for
Outpatient Physical,
Occupational or
Speech Therapy (up to
60 treatment days per
disability)
$250 per inpatient day
copayment
$750 max. per
admission
Must be preauthorized
$25 copayment per
visit
Must be preauthorized
No copayment per visit
up to age 21
$25 copayment per
visit age 22 and over
limited to 1 per year
Covered for children up
to age 18 only
20% coinsurance
No copayment for
inpatient rehabilitation
$50 Specialist
copayment per visit for
outpatient
Limited to 60 days per
illness or injury
$1,000 copay per
admission
$35 PCP
$0 PCP copay per visit
No Charge (Ages 0-17)
20% coinsurance for
adults age 18 and
over. Limited to a
single hearing aid every
3 years. Maximum
benefit of $5,000 per
calendar year.
Inpatient: No Charge
Outpatient: $35 PCP
$50 Specialist copay
per visit
Combined limit of 60
treatment days per
medical episode
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 21
Member pays 20% of
Allowed Charges after the
calendar year deductible
Certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Requires certification after 15
visits or penalty will apply
$30 Physician copay,$50
Specialist copay per office
visit for a
basic hearing screening
only (does not include a
comprehensive hearing exam)
One per calendar year
*See Choice of Provider
Benefit limited to
children up to age 18;
audiological services and
hearing aids are covered as
Durable Medical Equipment.
No benefits for ages 18 and
over; certification
required
Member pays 20% of Allowed
Charges after calendar year
deductible.
Certification required after 20
visits.
Each service limited to 60
visits per year
Member pays 50% of Allowed
Charges after the calendar
year deductible and $300 per
confinement hospital deductible,
plus amount above the Allowed
Charges and all ineligible
expenses.
Certification required
Member pays 50% of
Allowed Charges after the
calendar year deductible, plus
amount that exceeds the Allowed
Charges & all ineligible expenses.
Requires certification after 15
visits or penalty will apply
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Basic hearing screening only
Benefit limited to children up to
age 18; audiological services
and hearing aids are covered as
Durable Medical Equipment.
No benefits for ages 18 and over;
certification required
Member pays 50% of Allowed
Charges after calendar year
deductible plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Certification required after 20
visits. Each service limited to 60
visits per year
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Member pays 20% of
Allowed Charges after the
calendar year deductible
Certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Requires certification after
15 visits or penalty will apply
$50 copay per visit after the
calendar year deductible for
a basic hearing screening
(does not include a
comprehensive hearing
exam)
One per calendar year
Benefit limited to
children up to age 18;
audiological services and
hearing aids are covered as
Durable Medical Equipment.
No benefits for ages 18 and
over; certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required after 20
visits.
Each service limited to 60
visits per year
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
22 2012 Employees Benefits Council of the Office of State Finance
Chiropractic &
Manipulative Therapy
Durable Medical
Equipment (DME)
Blood and Blood
products
Skilled Nursing Facility
Periodic Health Exams
$40 Specialist per visit
limited to 15 visits per
calendar year
20% for initial
device/20% for repair and
replacement
No Charge
No Charge
No Charge
$50 copay per visit
(15 visits per year)
(PCP prior
authorization
required)
20% copay
(prior authorization
required)
No copay
No copay
(Limit: Max 100 days
per year)
$0 copay
Routine Physicals
$50 copayment per
visit
Must be preauthorized
20% coinsurance
No copayment
Limit: 100 days per
Plan Year
$250/day copayment
$750 max. per
admission
No copayment per
PCP limited to 1 per
year
$50 Specialist copay
per visit;
15 visits per calendar
year,
limited to treatments of
neurological and
orthopedic conditions
(Referral required)
20% coinsurance
Applies Autologous,
donor directed, and
donor designated blood
processing costs are
limited to $120 per
unit and must be for a
scheduled procedure
$1,000 copay per
admission;
Limited to 100
consecutive days/
calendar year
$0 PCP copay per visit
$50 Specialist copay
per Visit
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 23
Member pays 20%
of Allowed Charges after
calendar year deductible
Certification required after 20
visits. Each service limited to
60 visits per year
Member pays 20% of
Allowed Charges after the
calendar year deductible for
covered items.
Purchase, rental, repair, or
replacement must be certified
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of Allowed
Charges after
the calendar year deductible.
Certification required
Limit: 100 days per year
$0 copay for one preventive
services visit per calendar
year for members and
dependents age 20 and older.
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
One mammogram per year at
no charge for woman age 40
and older. For woman under
age 40, $30 Physician copay
or $50 Specialist copay per
office visit. Some guidelines
apply
*See Choice of Provider
Member pays 50% of Allowed
Charges after calendar year
deductible plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Certification required after 20
visits.
Each service limited to 60
visits per year
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Purchase, rental, repair, or
replacement must be certified
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount above Allowed
Charges and all ineligible
expenses
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required
Limit: 100 days per year
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
No copay or deductible
for one mammogram per
calendar year for women age
40 and over, member pays
charges over $115. Some
guidelines apply
One preventive services
visit covered at 100%
of Allowed Charges for
members and dependents
age 20 and older. H.E.L.P.
Check program pays primary
member $100 for completing
preventive services visit,
metabolic and lipid panels,
and health risk assessment.
Member pays 20% of Allowed
Charges after the calendar
year deductible
Certification required after 20
visits. Each service limited to
60 visits per year
Member pays 20% of Allowed
Charges after the calendar
year deductible for covered
items. Purchase, rental,
repair, or replacement must be
certified
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Limit: 100 days per year
$0 copay for one preventive
services visit per calendar
year for members and
dependents age 20 and older.
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
One mammogram per year at
no charge for woman age 40
and older. For woman under
age 40, $30 Physician copay
or $50 Specialist copay per
office visit. Some guidelines
apply
*See Choice of Provider
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
24 2012 Employees Benefits Council of the Office of State Finance
Temporomandibular Joint
(TMD) Dysfunction
Home Health Services
Medical Transportation
Transplants
Hospice
Preventive Services
Eye Care
$50 per treatment plan
Lifetime non-surgical
maximum of
$1,500
Surgery is under medical
No Charge
No Charge
No Charge
No Charge
$100 copay per
treatment plan
(lifetime non-surgical
maximum of $1,500)
No copay
(prior authorization
required)
Ambulance No copay
(must have prior
authorization except
for emergencies)
No copay (all
transplant
services, including
evaluations must be
preauthorized)
No copay
$10 copay
Vision Screening and
Refraction (one every
365 days) Contact
Members Services for
a contracted provider
$100 copayment per
treatment plan
NOTE: Lifetime
non-surgical maximum
of $1,500. Surgical is
under medical.
$25 copayment per
visit
Must be prescribed by
PCP
$100 copayment
Inpatient copayment
applies
Preapproval and
precertification
required
No copayment
for terminal illness
of six months or less
Preapproval required
$50 copay,
$1,500 lifetime
maximum for
nonsurgical benefits
$50 copay per visit
No Charge
Non-emergency
transportation requires
prior authorization.
$1,000 per admit
$50 copay per visit
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 25
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Limit: 100 visits per calendar
year
Member pays 20% of Allowed
Charges after the calendar
year deductible.
If not an emergency,
medically necessary services
require certification
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar
year deductible. For life
expectancy of six months or
less
Certification is required
Age 20 and older, no charge
one time per calendar
year for preventive service
visit, metabolic panel, and
comprehensive lipid panel
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required Limit:
100 visits per calendar year
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
If not an emergency, medically
necessary services require
certification
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses. For life
expectancy of six months or
less Certification is required
Member pays 50% of Allowed
Charges after the individual
calendar year deductible,
plus amount above Allowed
Charges and all ineligible
expenses
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Age 20 and older, no charge
one time per calendar
year for preventive service
visit, metabolic panel, and
comprehensive lipid panel
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required
Member pays 20% of
Allowed Charges after
the calendar year deductible.
Certification required Limit:
100 visits per calendar year
Member pays 20% of
Allowed Charges after the
calendar year deductible.
If not an emergency,
medically necessary services
require certification
Member pays 20% of
Allowed Charges
after the calendar year
deductible.
Certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
For life expectancy of six
months or less
Certification is required
Age 20 and older, no charge
one time per calendar
year for preventive service
visit, metabolic panel, and
comprehensive lipid panel
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
26 2012 Employees Benefits Council of the Office of State Finance
Health care reform update
In 2011, state employees and their families saw several
changes in their health plans, thanks to the Patient
Protection and Affordable Care Act passed by Congress
and signed by the President. In contrast, 2012 will bring
few, if any, noticeable changes.
Once again, HMO plans will cover most preventive
services at 100 percent provided the services are done
In-network. In 2012, HealthChoice will also cover most
preventive services at 100 percent. For you, this means
no-cost access to such services as:
• Blood pressure, diabetes, and cholesterol tests
• Many cancer screenings
• Counseling from your health care provider on topics
including quitting smoking, losing weight, eating
better, treating depression, and reducing alcohol use
• Routine vaccines for diseases such as measles,
meningitis or tetanus
• Flu and pneumonia shots
• Counseling, screening and vaccines for healthy
pregnancies
• Regular well-baby and well-child visits, from birth to
age 21
(See the Health Plan Comparison section of this guide
for details.)
CAUTION:
Make Sure Your Dependents Are Eligible
Are you covering an ineligible dependent? Enrolled
ineligible dependents can result in significant and
unnecessary costs to the State and its employees. Even
the very conservative estimates put the value in the
millions of dollars.
Now is the time to make sure the dependents you
claim are eligible for state coverage.
Although no official action has been taken, an audit is
being considered. Philip K. Kraft, Executive Director
of the Employees Benefits Council of the Office of
State Finance, has directed staff to prepare for a
comprehensive dependent audit for Plan Year 2013.
A dependent eligibility audit is a controlled process
designed to preserve the integrity of an employer’s
benefit plan by identifying enrolled, but ineligible
participants. Examples include:
• Ineligible spouses
• Member forgets to inform employer of a divorce
• Once a divorce decree is issued, the employee’s
spouse is no longer an eligible dependent and
does not qualify for state benefits. If the court
orders the employee to provide the spouse with
health (or other) insurance, that coverage cannot
be through the State and will need to be obtained
from another source.
• Ineligible children
• Grandchildren, nieces and nephews (unless
employee has been granted legal custody)
• Spouses of married dependents (daughter in-law
or son in-law)
While there are financial benefits to a dependent audit, it
is by no means a popular move. However, an audit may
become necessary as a way to reduce costs in state
government, to validate insurance claims and to make
sure the State is in compliance with federal laws.
While the “honor system” is still in effect for Plan Year
2012, protect yourself by verifying the eligibility of all the
people you are claiming as dependents. If you’re unsure
whether a dependent is eligible, contact your Benefits
Coordinator or the Employees Benefits Council at (405)
232-1190 or 1-800-219-8115.
2012 Benefits Enrollment Guide 27
Mental Health Parity and Addiction Equity
Federal law, the Mental Health Parity and Addiction
Equity Act of 2008, requires health insurance providers
to include mental health and substance abuse coverage
equal to physical health coverage in terms of the
financial and treatment requirements. The law removed
differences in co-pays and removed limits on visits and
treatment days. Provisions of the law will be in effect in
all of the state’s available health plans in 2012.
Benefits Enrollment Calculator
Your benefits costs can be easily estimated using the
online Benefits Enrollment Calculator located on the
EBC web site at www.ebc.ok.gov. Be sure to choose
the monthly calculator if you are paid once a month
and the bi-weekly calculator if you are paid every two
weeks. The Benefits Enrollment Calculator can add
your benefits costs, apply your benefits allowance and
provide an estimated total, showing any out-of-pocket
expense or additional take-home pay you may realize in
your paycheck.
Important Notes about the Enrollment Calculator:
• Print your benefits calculator results for easy reference
during online enrollment.
• Use the calculator as many times as you want,
but to actually enroll you must use the Benefits
Administration System (BAS) link on the web site or
complete your paper enrollment form.
• The online Benefits Calculator provides estimates
only. Although every attempt has been made to
provide accurate information, the calculator provides
no guarantee of compensation, benefits or tax
implications.
Online Enrollment
Hit the “Easy Button” – Enroll Online!
Remember: Online Enrollment opens
October 3 and closes October 28, 2011.
Customer assistance is available October 3rd through
27th from 8 a.m. – 4 p.m. and October 28th from 8 a.m.
– 8 p.m. Assistance is also available by submitting a
help ticket through the help desk of the EBC website at:
www.ebc.ok.gov
Last year, 78 percent of state employees went to ebc.
ok.gov and used online enrollment to make their benefit
elections. Join your co-workers and discover how easy
it is to enroll online. The average enrollment takes just
a few minutes and you can log on anytime, 24 hours a
day, seven days a week during Option Period.
Online Enrollment allows you to:
• Print your confirmation of elections instantly
• Update address and telephone information online
• Change your elections and make corrections as
many times as you like, until the close of Option
Period (remember, your final election is the official
enrollment!)
1. Look for the Welcome Letter distributed by your
Benefits Coordinator. Find your User ID and
password.
2. Log on to EBC’s secure web site, www.ebc.ok.gov.
Sign on to the Benefits Administration System using
instructions found in your Welcome Letter.
3. Change password: Follow instructions to set your
personal password.
4. Choose Online Enrollment and begin.
On the home page of ebc.ok.gov, the Benefits
Administration System (BAS) access window is in the
top right corner of the screen. Inside BAS, updated
videos featuring step-by-step online enrollment
instructions are available. Online enrollment is not
currently available for newly hired employees outside of
Option Period.
Eligibility Reminder:
If you experience a qualifying life event during the
year; for example, marriage, divorce, birth or adoption,
you may be allowed to make certain changes to your
insurance elections without waiting for Option Period.
You must complete a change form within 30 days of
the life event (see page 39 for a full list), or wait until the
next Option Period to make any changes.
Remember, it is a 30-day deadline!
Help is available by phone at the Employees Benefits
Council: (405) 232-1190 or 1-800-219-8115.
28 2012 Employees Benefits Council of the Office of State Finance
Invisible Bracelet
Like a virtual medical ID bracelet, the Invisible Bracelet
may help save your life during emergencies. The early
medical alert involves an eight-digit code that appears
on a keychain fob and/or a sticker to be placed on
the back of your driver’s license. The fob can also be
attached to a child’s backpack.
If you are
unconscious or
otherwise unable
to be understood,
emergency medical
service providers
can enter your code
on a secure, HIPAA-compliant
web site
and get valuable
information in
seconds, including
your identity, medications, allergies, chronic conditions,
insurance and emergency contacts.
First responders in many communities around
Oklahoma, such as EMSA, are already trained to look
for the fob or sticker. The information they’ll find is
entered by you, so it’s important to keep the information
current. Invisible Bracelet offers “Auto Reminders” to
help you keep your health information and emergency
contacts up to date.
Employees, spouses and other eligible dependents
can take advantage of this benefit. The cost is only $3
per person, per year. So, for example, if an employee,
spouse and two children all get Invisible Bracelets,
the cost will be $12. The membership fee(s) will be
deducted during the employee’s first pay period
of 2012. The Invisible Bracelet benefit is a pre-tax
deduction for employees who choose premium
conversion.
To learn more about this innovative “Made in Oklahoma”
service or to see if the service is available in your area,
visit www.invisiblebracelet.org.
Flexible Spending Accounts (FSAs)
Want to Save More On Your Taxes?
FSAs are money-saving ways to pay for qualified health,
day care and mass transit expenses because the
accounts are funded with pre-tax dollars. Here’s how
the average person, contributing just $100 per month,
can increase their take-home pay by using an FSA:
Without FSA With FSA
Annual Salary $35,000 $35,000
FSA Deposit (annual) 0 1,200
Taxable Income 35,000 33,800
Estimated Taxes (30%) - 10,500 -10,140
Health Care Expenses - 1,200 0
Take Home Pay 23,300 23,660
Annual Increase in
Take Home Pay $360
FSAs can no longer be used to pay for some over-the-
counter drugs and health products without a
prescription. Check out the list of eligible items provided
at ebc.ok.gov in the “Flexible Spending” section.
Experience the Convenience of the
Free FSA Debit Card!
It’s fast, flexible and free! The optional Flexible Spending
Account (FSA) debit card can be used at hundreds of
merchants.
Simply present the FSA debit card to pay for medical
and dependent care expenses. The money is taken
directly from your FSA account, resulting in fewer paper
claims to file.
When using the FSA debit card, some charges may
require proof after purchase. Save your receipts!
Please Note the Following:
• FSAs have a “Use it or Lose it” rule. Simply stated, if
you have money left in your account after March 15th
of the following year, that money will be forfeited. But
don’t let that scare you. With a little planning, you can
take advantage of this tax-reducing benefit without
losing any money.
• Debit cards are not currently available for use in the
Mass Transportation Accounts. FSA debit cards are
available only in conjunction with the health and
dependent care accounts.
• You cannot enroll in a Flexible Spending Health Care
Account if you choose the HealthChoice S-Account
Plan.
Oklahoma
Company
2012 Benefits Enrollment Guide 29
• You may be restricted from enrollment in the
HealthChoice S-Account if you have funds remaining
in your FSA Health Care Account on January 1, 2012.
• In limited circumstances, you may be eligible to roll
over certain remaining amounts from your FSA Health
Care Account to your newly established HSA account.
• You can continue to participate in the FSA Dependent
Care Account or the New Mass Transportation
Account if you elect the HealthChoice S-Account
Plan.
Grace Period Extension
The IRS allows a grace period for incurring approved
expenses from your FSA. You have until March 15th of
the following year to use funds from your current year’s
account.
So go to the doctor, buy a prescription or incur any
approved expenses such as bandages, diabetes testing
supplies, and contact lens solution until March 15th,
2013 and still file for reimbursement from your remaining
2012 FSA account fund. Check out the full list of eligible
products in the Flexible Spending section of www.ebc.
ok.gov.
When calculating your FSA contribution for Plan Year
2012, it is important to plan conservatively. Calculate
based on your Plan Year estimated expenses. Do not
include the extended grace period in your calculations.
This extension may help you reduce the risk of losing
unused funds in your FSA accounts.
Add Up Your Savings with our
FSA Savings Calculator
• How much in taxes will I save?
• How much should I contribute annually?
• What expenses should I consider when calculating my
contribution?
To see how you might benefit from enrolling in an FSA,
log on to www.ebc.ok.gov and use the FSA savings
calculator. It can help you estimate your qualifying
annual expenses and calculate how much you can save
in taxes by paying for your health care and dependent
care expenses on a pre-tax basis.
Health Care Account (HCA)
By signing up for a Health Care Account,
you can set aside up to $5,000 for you
and your family’s health care related
expenses. Realize significant tax savings
on qualified, un-reimbursed expenses by paying for the
services and items pre-tax. Enroll for an HCA online or
with your paper enrollment, indicating the pay period
contribution you want deducted from your paycheck.
Some qualifying expenses include:
• Doctors visits, deductibles and copays
• Prescription drugs
• Vision care, laser eye surgery, eyeglasses or lenses
• Dental care, orthodontic expenses
• Physical therapy
As many FSA users are already aware, restrictions on
pre-tax purchases of some over-the-counter (OTC)
medications like Tylenol and Claritin took effect in 2011
and will continue to be in place for 2012. In accordance
with a provision of the health care reform law, OTC
drugs, medicines and biologicals can be purchased with
Health Care FSA funds, but only with a letter of medical
necessity from a medical provider. Also, the items can
no longer be purchased with the “Benny” debit card.
However, products like bandages and contact lens
solution will still be allowed as Benny card purchases.
Check out the list provided at ebc.ok.gov in the
“Flexible Spending” section.
HCA Monthly Minimum: $10
HCA Monthly Maximum: $416.66
30 2012 Employees Benefits Council of the Office of State Finance
Dependent Care Account (DCA)
Daycare expenses can add up quickly. By contributing
to a Dependent Care Account, you can pay for child
or adult daycare with pre-tax dollars resulting in
substantial tax savings. Monthly contributions are
deducted from your paycheck before your taxes are
calculated. Enroll for the DCA online or by paper, but be
sure to indicate your pay period contribution.
DCA Monthly Minimum: $50
DCA Monthly Maximum: $416.66
Mass Transportation Accounts (MTA )
By enrolling in this option, employees can have pre-tax
deductions directed to this account for employees to
utilize mass transit and be able to be reimbursed for
bus tokens with pre-tax funds for their commute to and
from state employment. This account is designed for
Employees’ use only. You may be reimbursed only for
the employee’s use of Mass Transit. No reimbursement
for dependents is permissible. To utilize the account,
you simply enroll any time during the plan year (this
account does not require a family status event). You
will then purchase a monthly mass transit pass from
your area provider and submit a copy of the pass along
with a claim form to EBC. You will be reimbursed once
funds are in your Mass Transit Account. The maximum
amount you can contribute is $115 a month ($1,380
annually). You are allowed to change your monthly
election during the plan year between a minimum of
$10 to the maximum of $115. You may also discontinue
the account during the year if your needs change. See
your Benefits Coordinator for additional information or
contact EBC.
MTA Monthly Minimum: $10
MTA Monthly Maximum: $115
• See additional important rules and regulations for
Mass Transit accounts on page 38 of this Guide.
Important Notes on FSA Accounts:
• You must re-enroll every year.
• Indicate your per-pay-period contribution on your
enrollment (not your annual contribution).
• View account balances and claim information on line
by logging onto the Benefits Administration System
(BAS) via the EBC website at www.ebc.ok.gov. After
logging in using your employee ID and password,
select Flexible Spending from the left menu.
• See additional important rules and regulations for
FSAs on page 37 of this Guide.
HealthChoice S-Account Plan
The S-Account Plan is a qualified high deductible health
plan to be used exclusively with a Health Savings
Account (HSA).1
• For information on participating in this account on a
pre-tax basis, contact EBC at (405) 232-1190, ext. 110.
• Please note the following:
• You cannot enroll in a Health Care flexible
spending account (FSA) if you choose the
HealthChoice S-Account Plan. You may, however,
elect either the Dependent care account and/or
the Mass Transportation account if you have a
HSA.
• You may be restricted from enrollment in the
HealthChoice S-Account if you have funds
remaining in your Health Care flexible spending
account on January 1, 2012.
• In limited circumstances, you may be eligible to
roll over certain remaining amounts from your
Health Care flexible spending account to your
newly established HSA account.2
The $1,500 individual/$3,000 family deductible for the
HealthChoice S-Account Plan must be met before any
health or pharmacy benefits are paid by the plan. There
are certain exceptions for preventive care. Refer to the
Health Plan Comparison Section for details.
1 Although OSEEGIB and the Health Savings Account (HSA)
trustee/custodian together provide health insurance benefits,
each are independent entities with separate responsibilities.
OSEEGIB expressly disclaims any fiduciary obligation to manage
the member’s HSA funds or accounts. HSA account information
concerning contributions, IRS determinations, withdrawals, or any
matters regarding the HSA is the sole responsibility of the HSA
trustee/custodian chosen by the member.
2 Confer with your tax professional for possible eligibility questions
and tax consequences of enrollment in a high deductible health plan
and health savings account.
For further information, contact OSEGIB at
405-717-8780 or toll-free 1-800-752-9475
2012 Benefits Enrollment Guide 31
Employee Life Insurance
All eligible current state employees are covered by the
HealthChoice Life Insurance Plan which provides a
$20,000 basic term life insurance policy called Basic
Life. An additional term life policy, called Supplemental
Life, is available in $20,000 units for employees who
need more coverage.
Basic Life Coverage
As a state employee, you are automatically enrolled
in Basic Life. This also includes Accidental Death and
Dismemberment (AD&D) coverage.
Supplemental Life Coverage
You can elect to increase your life insurance coverage
in $20,000 units up to a maximum of $500,000. To
increase your coverage, a Life Insurance Application
must be submitted and approved. Your application
must be approved before coverage can take effect. The
postmark deadline for submitting the Life Insurance
Application is Tuesday, November 15, 2011.
AD&D Coverage
Basic Life ($20,000) and the first unit ($20,000) of
Supplemental Life include Accidental Death and
Dismemberment coverage. AD&D coverage pays
additional benefits for the loss of life, loss of limb
or limbs, or the loss of sight. See the HealthChoice
Life Insurance Handbook for more information. The
handbook is available online at www.healthchoiceok.
com or www.sib.ok.gov.
Guaranteed Issue (New employees only)
You may enroll in life insurance coverage in an amount
up to two times your base annual salary without
completing a Life Insurance Application. See your
Benefits Coordinator for details.
How to Increase Your Life Insurance
Coverage
To increase your life insurance coverage, please
complete a Life Insurance Application and obtain your
Coordinator’s signature, if required. Mail directly to
the Oklahoma State and Education Employees Group
Insurance Board (OSEEGIB), a division of the Office of
State Finance. The address is located on the back of
the form.
For a complete description of life insurance coverage,
eligibility and benefits, please refer to the HealthChoice
Life Insurance Handbook. The handbook is available
online at www.healthchoiceok.com or www.sib.ok.gov.
Dependent Life Insurance
You have three options to choose from when purchasing
dependent life insurance coverage:
Dependent Life Premier Option
• $20,000 term life policy for spouse
• $10,000 term life policy for each child
• $1,000 term life policy for newborns to 6 months
Dependent Life Standard Option
• $10,000 term life policy for spouse
• $5,000 term life policy for each child
• $1,000 term life policy for newborns to 6 months
Dependent Life Low Option
• $6,000 term life policy for spouse
• $3,000 term life policy for each child
• $1,000 term life policy for newborns to 6 months
To enroll, complete the back of your enrollment form or
select this option during your online enrollment.
Monthly Premium
Basic Life ($20,000)
Includes AD&D . . . . . . . . . . . . . . $4.00
First $20,000 Supplemental Life
Includes AD&D . . . . . . . . . . . . . . $4.00
Additional Units of Supplemental Life
Age-Rated (Per $20,000)
Under 30 years . . . . . . . . . . . . . . . . . $0.60
30-34 years . . . . . . . . . . . $0.60
35-39 years . . . . . . . . . . . . . . $0.80
40-44 years . . . . . . . . . . . . . . $1.20
45-49 years . . . . . . . . . . . $2.00
50-54 years . . . . . . . . . . . . . $3.40
55-59 years . . . . . . . . . $5.40
60-64 years . . . . . $6.20
65-69 years . . . . . . . . . . . $10.20
70-74 years . . . . . . . . . . . . . . $17.40
75+ years . . . . . . . . . . . . . . $27.00
Dependent Life
Low Option . . . . . . . . . $2.60
Standard Option . . . . . . . . . $4.32
Premier Option . . . . . . . . . . . $8.64
Disability . . . . . . . . . . . . . . . $9.10
32 2012 Employees Benefits Council of the Office of State Finance
Assurant Freedom Preferred
www.assurantemployeebenefits.com
Deductibles
$25 per person
(Waived for
Class A Services)
$25 per person None None
100% of allowable
amounts
Includes routine
cleanings, check-ups
and some
X-rays for adults
and children, and
fluoride treatments
100% of allowable
amounts
Includes routine
cleanings, check-ups
and some
X-rays for adults
and children, and
fluoride treatments
Example Services
Copays
Sealant per tooth:
$22 copay Routine
Cleaning (once every
6 months): No charge
Topical Fluoride
Application (up to age
18): No charge
Periodic Oral
Evaluations: No charge
Example
Services /Copays
Sealant per tooth:
$15 copay
Routine Cleaning
(once every 6 months):
No charge
Topical Fluoride
Application (up to age
18): No charge
Periodic Oral
Evaluations: No charge
85% of allowable
amounts after
deductible.
Includes fillings,
some X-rays,
extractions,
periodontal care, and
some root canal oral
surgery
70% of allowable
amounts after
deductible.
Includes fillings,
some X-rays,
extractions,
periodontal care, and
some root canal oral
surgery
Example
Services/Copays
Amalgam - one
surface, permanent
teeth $32
Example
Services/Copays
Amalgam - one
surface, permanent
teeth $25
60% of allowable
amounts after
deductible
50% of allowable
amounts after
deductible
Example
Services/Copays
Root Canal,
Anterior $175
Periodontal/Scaling/
Root Planing 1-3
teeth (per quadrant)
$54
Endodontist: 15
percent discount
Example
Services/Copays
Root Canal,
Anterior $165
Periodontal/Scaling/
Root Planing 1-3
teeth (per quadrant)
$36
Speciality rider
pays specialist at set
copays.
No deductible, plan
pays 60% up to
lifetime maximum
of $2,000
No deductible, plan
pays 50% up to
lifetime maximum
of $2,000
25% discount for
Adults and Children
25% discount for
Adults and Children
Assurant Heritage
www.assurantemployeebenefits.com
Annual
Maximum
Benefit
$2,000 per person
per calendar year
$2,000 per person
per calendar year
No plan year dollar
maximum
No plan year dollar
maximum
(Requires choosing a
primary care dentist)
(Requires choosing a
primary care dentist)
Basic Care
(Class B)
Includes fillings, extractions,
periodontal care, root canal,
and oral surgery
Preventive Care
(Class A)
Includes routine cleanings,
check-ups, X-rays and
topical fluoride treatments
Major Care
(Class C)
Includes crowns, bridges
and dentures
Orthodontic Care
(Class D)
2012 Dental Plans
See the Dental Monthly
Rates on page 5. In-Network Out-of-Network Secure
Prepaid Plan
Plus
Prepaid Plan
2012 Benefits Enrollment Guide 33
Important Details
about Dental Coverage:
• Pay special attention to the plan’s participating dentists. Call to confirm your dentist accepts your
selected plan. Be specific in your questions. For example, ask if the dentist participates as a Delta
Dental PPO network provider, not just if they accept Delta Dental.
• If you choose a dentist out-of-network, you will receive lower benefits and may be subject to
additional costs.
• Dental prescriptions are covered under health plan benefits.
None
$5 office copay
applies
$25 per person
per calendar year-
Classes B & C only
$50 per person
per calendar year-
Classes A, B and C
only
$100 deductible per
person on Major
Services only
(level 4)
$25 per person
Basic Care and
Major Care
combined;
$25 per person
Preventive, Basic,
and Major Care
combined
Example Services
Copays Sealant per
tooth: $15 copay
Routine cleaning (once
every 6 months): no
charge
Topical Fluoride
Application (up to age
18): no charge
Periodic Oral
Evaluations: no charge
100% of allowable
amounts No
deductible applies
100% of allowable
amounts after
deductible
Schedule of
Covered Services
and Enrollee
Copayments:
Example Services/
Copays Routine
Cleaning: $5 copay
Periodic oral
evaluations:$5 copay
Topical fluoride
application (up to age
19): $5 copay
100% of
allowed charges
100% of
allowed charges
after the deductible
Example
Services/Copays
Root Canal,
Anterior $355 copay
Periodontal Scaling/
Root planning 1-3
teeth (per quadrant)
$71 copay
60% allowable
amounts after
deductible
50% allowable
amounts after
deductible
Schedule of
Covered Services
and Enrollee
Copayments:
Example Services/
Copays Crown-porcelain/
ceramic
substrate: $241 copay
Complete denture-maxillary
$320 copay
60% of
allowed charges
after deductible
50% of
allowed charges
after deductible
$2,280 out-of
pocket child;
$3,120 out-of-pocket
adult (24 month
treatment); excludes
orthodontic treatment
plan and banding.
60% of allowable
amounts up to
$2,000 lifetime
maximum
60% of allowable
amounts up to
$2,000 lifetime
maximum
You pay charges in
excess of $50 per
month. Lifetime
maximum up to
$1,800
50% of allowed
charges 12-month
waiting period
may apply*
No deductible or
lifetime maximum
for Network or
Non-Network
50% of allowed
charges 12-month
waiting period
may apply*
No deductible or
lifetime maximum
for Network or
Non-Network
Prepaid Plan
(Requires choosing a
primary care dentist)
PPO
In-Network and
Out-of-Network
Premier
In-Network and
Out-of-Network
PPO - Choice
Delta Dental
PPO Network
Network Provider Non Network
Provider
CIGNA Dental
www.cigna.com
Delta Dental
Example
Services/Copays
Amalgam - one
surface, permanent
teeth $21
85% allowable
amounts after
deductible
70% allowable
amounts after
deductible
Schedule of
Covered Services
and Enrollee
Copayments:
Example Services/
Copays Amalgam one
surface, primary or
permanent tooth $12
copay
85% of
allowed charges
after deductible
70% of
allowed charges
after deductible
No plan year dollar
maximum
$2,500 per person
per calendar year
$3,000 per person
per calendar year
$2,000 per person
per calendar year
$2,000 per person
per calendar year
Preventive, Basic,
and Major Care
combined
$2,000 per person
per calendar year
Preventive, Basic,
and Major Care
combined
Delta Dental Delta Dental HealthChoice Dental
www.DeltaDentalOK.org www.DeltaDentalOK.org www.DeltaDentalOK.org www.healthchoiceok.com
34 2012 Employees Benefits Council of the Office of State Finance
Disability Insurance
No one expects to become disabled, but
the financial burden can be eased by
your coverage under the HealthChoice
Disability Plan. Disability coverage pays
an amount equal to 60 percent of your
base salary up to a maximum dollar limit based on your
age, salary, and years of service from the onset of your
disability.
Eligibility
Disability benefits are available to all employees who
have completed at least one month of continuous
employment. No benefits are payable for any disability
caused by a pre-existing condition.* Claims must
be filed within one year of the date you first became
disabled.
Definition of Disability
Disability is defined as the inability to perform the major
duties of your job. After two years of disability, it is
defined as the inability to perform the duties of any job
for which you are or may become reasonably qualified
by training, education or experience.*
What the Plan Pays
The disability plan will pay a monthly income equal to
60 percent of your base pay up to a maximum (minus
offsets).
Monthly Maximum Disability Income
• Short-Term: $2,500
• Long-Term: $3,000
Benefits paid will be offset by any other income you
may receive such as Social Security Disability, Workers’
Compensation, Leave, or Disability Retirement.
When the Plan Pays
Payments begin after you have been disabled for 30
days. Short-term disability pays a benefit for the first
150 days. Generally, long-term disability pays a benefit
after 180 days of disability and continues to age 65 or
recovery, whichever is first, based on age, salary, and
years of service at the onset of your disability. Other
limitations may apply.
*For a complete description of the disability plan’s eligibility and
benefits, please refer to the HealthChoice Disability Insurance
Handbook. The handbook is available online at
www.healthchoiceok.com or www.sib.ok.gov.
Employee Assistance Program (EAP)
The EAP is a cooperative effort between employees and
administration, offering employees and their families
an opportunity to seek and receive free assistance
in resolving personal issues. Some of these issues
include family, financial, emotional, alcohol/drug abuse,
addiction, trauma, and work relationships, which
adversely affect safe and efficient performance on the
job. The EAP is available to help employees deal with
personal issues before they result in deterioration of
health, family life, or job performance. EAP specialists
provide confidential assistance, information and
referrals for employees/family members in using their
behavioral health benefit and/or finding a community
resource. EAP specialists also consult with supervisors/
managers on how employees can be referred for
assistance. For more information, contact your agency’s
Human Resource Office, review Merit Rule 530:10-21-1
through 9, or go to EBC’s web site, ebc.ok.gov, click on
OKHealth, then Wellness, then Programs.
SoonerSave
SoonerSave – Prepare for
Retirement Wisely
SoonerSave is a voluntary
long-term retirement savings
plan available to State
employees only. It is a division of the Oklahoma Public
Employees Retirement System (OPERS) and is designed
to supplement the benefit you receive from your State
retirement system. SoonerSave is comprised of two
defined contribution plans: The Deferred Compensation
457 Plan and the Deferred Savings Incentive 401(a)
Plan. When you contribute money to SoonerSave, your
contribution is deposited in the Deferred Compensation
457 Plan. As an incentive to contribute to SoonerSave,
the State will contribute $25 per month to the Deferred
Savings Incentive 401(a) Plan.
SoonerSave is an excellent way to defer federal and
state taxes from your current income while saving for
the future. In both plans, contributions and any earnings
grow tax-deferred until money is withdrawn, usually
during retirement when the participant is typically
receiving less income and may be in a lower tax bracket
than while working.
A few reasons to join SoonerSave today include:
• Easy Enrollment and Savings—You can now enroll in
SoonerSave using the same Online Enrollment process
that you use to make your other benefit elections. Just
decide how much you want to contribute and how
you want it invested—then you are on your way to
investing for your retirement through convenient payroll
deduction.
You may also enroll in SoonerSave by going directly
to http://www.dcprovider.com/oklahoma/ and entering
your social security number and password (savenow).
• Tax Savings—Your contributions are deducted from
your paycheck before federal and state income taxes
are calculated—lowering your taxable income. Plus,
your contributions and any earnings grow on a tax-deferred
basis.
2012 Benefits Enrollment Guide 35
• Money from the State of Oklahoma—You will receive a
$25 state contribution each month just for participating
in SoonerSave.
• Tax Credit—Some SoonerSave participants may be
eligible for a tax credit to help save for tomorrow by
reducing taxes today. The amount of credit depends
on your adjusted gross income and filing status (e.g.,
single, married, head of household). To learn more
about the tax credit, you should consult your tax
advisor or visit www.irs.gov and search for “Saver’s
Credit” or Form 8880.
Are you already participating in
SoonerSave? Great! You’ve taken
the first step to preparing yourself
for retirement. Now, you may want
to take the next step and increase
your contribution amount using the
Online Enrollment process. Increasing your contributions
to SoonerSave by even a small amount could make a
big difference in your long-term retirement savings plan.
The table below illustrates the impact an increased
contribution could have on your account balance and the
benefit you receive from your account when you retire.
SoonerSave continued
$50/month $25/month $75/month $44,177 $279.48
$100/month $25/month $125/month $73,628 $465.81
$150/month $25/month $175/month $103,079 $652.13
$200/month $25/month $225/month $132,530 $838.45
Employee
Contribution
Amount
Employer
Contribution
Amount
Total
Contribution
Amount
SoonerSave
Balance After 20
Years*
Monthly Benefit for
20 Years (Before
Tax Withholding)*
* FOR ILLUSTRAT IVE PURPOSES ONLY. This hypothetical illustration does not represent the performance of any investment options. The
accumulation stage assumes an 8% rate of return, reinvestment of earnings and no withdrawals. The payout stage assumes 12 monthly
payments per year with a 4.5% rate of return. Withdrawals of tax-deferred accumulations are subject to ordinary income tax. This illustration
does not reflect any charges, expenses or fees that may be associated with your Plan. The tax-deferred accumulations shown above would
be reduced if these fees had been deducted. In order to properly plan for your retirement years, OPERS strongly encourages you to consider
participating in SoonerSave (if you are eligible) as a way to supplement the income you will receive from your defined benefit plan and Social
Security. For more information about SoonerSave or to update your beneficiary information, call 1-800-733-9008 or (405) 858-6781. You can
also obtain information, change your contribution amount or find enrollment forms by visiting www.soonersave.com. SoonerSave is a division
of the Oklahoma Public Employees Retirement System.
36 2012 Employees Benefits Council of the Office of State Finance
General
Enrollment in a medical or dental plan does not guarantee that a
particular doctor, dentist, clinic, or hospital will remain in your plan’s
network for the entire year. You enroll with the PLAN and not the
provider. If your provider terminates his or her contract during
the Plan Year, this does not allow you to change medical or
dental plan carriers. These benefits are effective January 1, 2012.
Keep this book as a reference throughout the year. This booklet
is only intended to be a brief summary of certain provisions of the
State of Oklahoma Employee benefit plans. In the event of a conflict
between the booklet and the laws of the State of Oklahoma or
administrative rules of the Employees Benefits Council (Council) and
the Oklahoma State & Education Employees Group Insurance Board
(Insurance Board), the laws and administrative rules shall govern in
all cases.
Dental
Out-of-network benefits may allow dentist to balance bill.
Balance Billing – the practice of a provider charging full fees and
billing the member for the portion of the bill insurance doesn’t cover.
Orthodontic benefits on the PPO options are typically only available
for dependents under the age of 19 or anyone with TMD. Contact
the plan to determine limits on Orthodontic benefits prior to
enrollment.
If new hires and/or new enrollees did not have group dental
coverage in effect prior to becoming covered under HealthChoice
Dental; and Assurant Freedom PPO a 12-month waiting period is
applied for orthodontic services.
*No waiting period applies for orthodontic benefits under the Delta
Dental plans.
See each dental plan’s website for a list of the dentists participating
in each plan’s network.
Delta Dental and Assurant Freedom Preferred both have statewide
and nationwide networks and will have the same benefits if
treatment is provided out of state.
**There is no applicable copayment schedule for Assurant Plan
Specialist services. Assurant Plan Specialists reduce their charges
as follows: a 15 percent discount off normal retail charges for
Endodontist and a 25 percent discount for any other Plan Specialist
including Orthodontist.
HealthChoice Dental Notes:
You are responsible for non-Network amounts that exceed the
Allowed Charges and for all non-covered services. Age limits and
restrictions may apply, please consult each plan.
Orthodontic benefits are only available to dependents under the age
of 19 with certification required for members greater than 19 years
of age. Contact the plan to determine limits on orthodontic benefits
prior to enrollment.
*If you are a new hire and/or a new enrollee and you did not have
group dental coverage in effect prior to becoming covered under
HealthChoice Dental; a 12-month waiting period will be applied to
orthodontic services.
See each dental plan’s website for a list of the dentists participating
in each plan’s network.
Consumer Information & Annual Notices
The Council and the Insurance Board comply with the HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996
known as HIPAA. The Council, the Insurance Board and each HMO,
dental, and vision plan offered to State employees has a Privacy
Notice which describes the organization protections and acceptable
uses of information. To obtain a Privacy Notice from a particular
plan, contact the plan directly or contact the Council. HIPAA also
provides you and your dependents certain rights to enroll if you
lose your group health plan coverage. HIPAA also prohibits a
group health plan from keeping you (or your dependents) out of
the plan based on anything related to your health. Finally, HIPAA
also gives you the right to buy certain individual health policies (or
in some states, to buy coverage through a high-risk pool) without
pre-existing condition exclusions. The HealthChoice medical
products offered by the Insurance Board are exempt from most of
the portability provisions of HIPAA including, but not limited to, the
following: limitations on pre-existing conditions, special enrollment
rights, discrimination based upon a health factor, standards for
mothers and newborns, mental health parity, and reconstructive
mastectomies. See the section on General Eligibility Information
for more details. The WOMEN’S HEALTH & CANCER RIGHTS ACT
of 1998, a Federal Law, provides benefits for mastectomy related
services including reconstruction and surgery to achieve symmetry
between the breasts, prostheses, and complications resulting
from a mastectomy (including lymphedema). The 1998 Guidance,
Questions and Answers, and Notice Requirements under WHCRA
(November 1998), can be obtained by calling 1-866-444-3272. The
BREAST CANCER PATIENT PROTECTION ACT, an Oklahoma State
Law, provides for at least 48 hours of inpatient care following a
mastectomy and not fewer than 24 hours following a lymph node
dissection. The NEWBORNS & MOTHERS ACT of 1996, a Federal
Law, requires the availability of a hospital stay of at least 48 hours
in connection with a vaginal delivery and not less than 96 hours
with a cesarean delivery. The PROSTATE CANCER PROTECTION
ACT, an Oklahoma State Law, provides for an annual screening for
early detection of prostate cancer in men age 50 and over and in
men from age 40-50 who are in high-risk categories. The Oklahoma
Prostate Surgery Side Effects Law provides that all health benefit
plans offered by OSEEGIB & EBC shall provide coverage for side
effects that are commonly associated with radical retropubic
prostatectomy surgery, including, but not limited to impotence
and incontinence, and for other prostate related conditions. THE
MANDATED BENEFIT FOR OB/GYN COVERAGE LAW requires any
health benefit plan offered in the state of Oklahoma which provides
medical and surgical benefits to also provide coverage for routine
annual obstetrical/gynecological examinations. The law does not
diminish already allowed health benefit diagnostics. In addition
the law also specifies that obstetrical/gynecological examinations
do not have to be performed by an obstetrician, gynecologist, or
obstetrician/gynecologist. If you have a problem which cannot be
resolved through your benefit plan’s grievance process, you may
have remedies with the Oklahoma State Department of Health,
Oklahoma Department of Insurance, or a remedy of law. Once you
become covered under a group health plan, you have certain rights
under the CONSOLIDATED OMNIBUS BUDGET RECONCILIATION
ACT of 1985 (COBRA). COBRA continuation coverage can become
available to you when you would otherwise lose your group health
coverage. It can also become available to other members of your
family who are covered under the Plan when they would otherwise
lose their group health coverage. For additional information about
your rights and obligations under the Plan and under federal
law, you can contact the Council or the Insurance Board. You
may also have rights under the Uniformed Services Employment
and Reemployment Rights Act (USERRA). USERRA protects
the job rights of individuals who voluntarily or involuntarily leave
employment positions to undertake military service. The law also
prohibits employers from discriminating against past and present
members of the uniformed services and applicants to the uniformed
services. See your agency for more information.
Benefits Details
2012 Benefits Enrollment Guide 37
Continued on Page 38
General Eligibility Information
The following are rules of eligibility that apply to commonly occurring
situations. The rules are listed in no particular order. This is not an
exhaustive list. Any active state of Oklahoma employee scheduled to
work at least 1,000 hours per year is eligible for benefits coverage if
he/she is not a temporary or seasonal employee. New Hire coverage
is effective on the first day of the month following the entry-on-duty
date. Coverage ends on the last day of the termination month.
All eligible dependents must be covered when one dependent is
covered under health, dental, or vision insurance unless proof of
other group coverage is provided. Eligible dependents can include
a spouse, children up to the age of 26 and incapacitated or totally
disabled children of any age if their incapacity occurred and was
verified prior to age 26. Two State employees cannot claim coverage
for the same dependents for health, dental, and vision benefits. The
Working Families Tax Relief Act of 2004 changed the definition of
dependent for federal income tax purposes, effective January 1,
2005. The IRS indicates that the change is not intended to affect
the coverage of dependents under employer sponsored medical
plans. However if you cover dependents, EBC suggests you obtain
professional tax advice when completing your income tax return(s).
Thirty-day written notice is required to reinstate coverage.
Electing a TRICARE Supplement Plan
Electing to purchase a TRICARE supplement plan means that
TRICARE will be primarily responsible for your medical coverage and
the supplement plan will be secondarily responsible for coverage. By
your election, you submit to the eligibility rules of TRICARE and the
TRICARE Supplement plan. These rules may be different from the
rules of eligibility created by the State of Oklahoma. Medicare may
become the primary insurer upon attaining eligibility for Medicare.
Changes to Benefit Plan Elections
Benefit elections made during the Option Period are generally
irrevocable. Changes can be made to Option Period elections only
if the change is authorized and consistent with Internal Revenue
Service regulations. If you experience an event which you believe
qualifies you to change your benefit elections, contact your Benefits
Coordinator within 30 days of the event. Life events that qualify
you to change your benefit elections include: marriage, birth,
adoption or placement of an adopted child, loss of other coverage,
change in marital status, change in the number of dependents,
change in employment status of employee, spouse or dependent
that affects eligibility, event causing employee’s dependent to
satisfy or cease to satisfy eligibility requirements, change in place
of residence of employee, spouse or dependent (HMO coverage),
commencement of or termination of adoption proceedings,
judgments, decrees or orders, Medicare or Medicaid, significant
cost increases (limited to Dependent Care Account using unrelated
care provider), changes in coverage of spouse or dependent under
other Employer’s plan (except HCA), FMLA Leave, or other such
events, which may permit such modification of election under the
IRS consistency rule as found in Treasury Regulations 1.125-4 and
in accordance with other applicable and prevailing Internal Revenue
Code regulations promulgated under, and in accordance with EBC
and OSEEGIB rules and regulations.
Flexible Spending Accounts Information
These accounts let you set aside money from your paycheck, pre-tax,
to pay for planned dependent care charges and expected
out-of-pocket healthcare expenses. You must enroll each Option
Period or you lose the account. Plan carefully when deciding your
contributions. Direct deposit of your reimbursements into the
same account as your payroll deposit is required by state law. If
you terminate employment with the state, any daycare or medical
services must be incurred prior to the last day of your termination
month. If you are not on active payroll (on some type of leave) it
is your responsibility to mail in your pledged contribution. Viewing
your account information is easy using the EBC website. For further
information on allowable expenses see EBC’s website at www.ebc.
ok.gov. Reimbursement can also be made for expenses incurred
by any participant during the Grace Period. The “Grace Period” is
the period from the end of the Plan Year through March 15th of the
subsequent Plan Year during which reimbursable expenses can
be incurred and attributable to the previous Plan Year’s account
balance. The final payment of benefits for any Plan Year may be
made following the close of such Plan Year based on accepted
claims filed with the Plan Administrator no later than the end of
the Run Out Period. The “Run Out Period” means the ninety (90)
day period following a Plan Year in which claims can be made for
reimbursable expenses incurred during the Plan Year. You cannot
pay for prior year expenses from current year account funds. All
expenses use the date of service, not the date they are paid for
eligibility purposes.
Debit Cards
The Council will reimburse an FSA participant for eligible expenses
incurred through use of the participant’s debit card provided the
participant properly activates the debit card, properly substantiates
the claim for expenses, and abides by the terms of use of the
debit card. The Council reserves the right to set the fee charged to
participants for use of the card, waive the annual fee, discontinue
use of the debit card, or require paper substantiation of expenses.
The rules of eligibility for Dependent Care Accounts and Health Care
Accounts apply to participants using the debit card. Upon demand
a participant shall immediately refund any overpayment made by the
Plan Administrator. Likewise, items charged to a debit card that are
unacceptable to the Plan Administrator will require a participant to
immediately refund such an overpayment to the Plan Administrator.
Amounts remaining in a participant’s healthcare and/or dependent
care accounts following final payment of all healthcare and/or
dependent care expenses incurred during the periods described in
OAC 87:10-25-9(b) shall be forfeited to pay administrative expenses
of the Flexible Benefits Plan.
FSA Health Care (Medical) Account Information
You spend your own money for after-insurance, qualified medical
expenses, deductibles, copays and certain over-the-counter items.
These expenses may be eligible for reimbursement according to
the IRS Code, enabling you to submit a claim voucher with the
appropriate documentation and receive reimbursement from your
own tax-free account. Attach the itemized bill and/or the Insurance
Explanation of Benefits (HealthChoice State Plan or Dental Indemnity
Plan EOB) to your signed EBC Expense Reimbursement Voucher
(claim form) and mail to the address on the form. Funds will be
disbursed for the amount requested within ten days of receipt if you
submit all required documentation. Check out the list of approved
over-the-counter items on the EBC website. Documentation required
for approved OTC items is the computerized receipt, name of
item, date of purchase, and amount paid. Pharmacy labels need to
include the printed name of the drug. The date of service is the date
you incur the expense (i.e. date you drop off the prescription at the
pharmacy, date you receive the medical care). This date must be
during the plan year and while actively participating in the program
(making monthly contributions). Claim deadlines are Fridays, at 1:00
p.m. (Subject to change during holidays).
FSA Dependent Care Account Information
If you have an eligible dependent (children 12 or younger who
have been included on your income tax return or any other eligible
dependent person physically or mentally incapable of self-care) who
spends at least eight hours a day in your home, you may want to
participate in the Dependent Care Flexible Spending Account. This
account pays daycare provider expenses while you and your spouse
work up to a combined calendar year total of $5,000. The daycare
provider cannot also be your tax dependent.
The individual calendar year limit is $2,500. Form 2441 must still be
filed with your taxes. You can receive reimbursement for the amount
you have currently deposited in your Dependent Care Account. With
proof of payment and the dates of service your daycare provider is
38 2012 Employees Benefits Council of the Office of State Finance
no longer req

2012 Benefits Enrollment Guide 1
OKHealth – New
and Improved!
In 2012, more than ever before, Wellness and Prevention will
be gateways to your benefits. All three of the available HMO
carriers will offer a new “Wellness Alternative Plus” plan. To take
advantage of the 25 dollar per month savings off the Alternative
rates, you must complete a brief Health Risk Assessment (HRA).
That HRA will open the door to the new-and-improved OKHealth
Wellness Program and to your better health.
OKHealth has been
reinvented to be much more
flexible, interactive and user-friendly.
Free, one-on-one
health coaching is available
for state employees who
need it, while many others
will be able to “self coach”
their way to better health by using the many resources available
on the new OKHealth web site.
It’s customized! In fact, as an active state employee, you already
have your own wellness page that can be tailored to fit your
individual needs! For a free, no-obligation preview of what’s
available, go to www.ebc.ok.gov and go to the OKHealth section.
The new web site includes social network functions where you
can interact with other state employees who share your wellness
goals. It has channels dedicated to weight management, fitness,
nutrition, stress management, financial health and even a place
to find a good laugh. YOU are the one who will decide what
topics fit your lifestyle and goals. If you want, you can chart your
progress with a food-intake tracker and exercise tracker. You’ll
also find articles and blogs related to your wellness interests and
calendars of wellness events.
All of our wellness services will continue to be FREE to active
state employees. All active state employees are encouraged to
participate; however, only the employees who choose a Wellness
Alternative Plus health plan will receive the financial incentive of a
discounted premium.
The new-and-improved OKHealth will be available to you starting
October 3rd – the first day of the Option Period for benefits
enrollment.
For more information about the exciting, new OKHealth program,
visit the OKHealth section of www.ebc.ok.gov.
Smarter, Healthier
Benefits Choices
Health Plans
Dental Plans
Vision Plans
Benefit Allowance
Sooner Save
OK Health Health
Mentoring Program State of Oklahoma
Employees Benefits Council
2012 Benefits
Enrollment Guide
Table of Contents
OKHealth . . . . . . . . . . . 1
Vision Plans . . . . . . . . . . 2
New Opt-Out Details . . . . . . . . . . . 4
Benefit Allowance . . . . . . . . 4
Plan Rates . . . . . . . . . . 5
Health Plans Comparison . . . . . 9
Dependent Eligibility . . . . . . 26
Benefits Enrollment Calculator . . . 27
Online Enrollment . . . . . . . . 27
Eligibility Reminder . . . . 27
Invisible Bracelet . . . . . . . . 28
Flexible Spending Accounts . . . . 28
Health Care Account . . . . . . 29
Dependent Care Account . . . . . 30
Mass Transportation Accounts . 30
Life, Supplemental life
& Dependent life . . . . . . . 31
Dental Plans . . . . . . . . . 32
Disability . . . . . . . . . . . 34
Employee Assistance Program . . . 34
SoonerSave . . . . . . . . . . 34
Benefits Details . . . . . . . . . 36
Glossary . . . . . . . . . . 39
of the Office of State Finance
Plan Year 2012
BENEFITS ENROLLMENT GUIDE
Active and New Employees of the State of Oklahoma
EBC 2012
2 2012 Employees Benefits Council of the Office of State Finance
vision Plans
It’s important for you to have
a good “vision” of what
combination of benefits choices
will fit you and your family
best. So this year, your benefits
office is placing an increased
emphasis on the eye-opening
benefits of a good vision plan.
Routine eye exams help keep
your vision sharp, allow eye
professionals to treat eye
infections and injuries more
effectively, and help them spot
early signs of eye conditions,
like astigmatism or glaucoma.
But the preventive advantages
don’t stop at the eyes. The
exams also help eye doctors
spot symptoms of diseases and
conditions like diabetes, high
blood pressure, osteoporosis
and brain tumors.
For Vision plan rates,
see pages 5 and 6.
Humana: If a member prefers contact lenses the plan
provides an allowance for the exam and contacts, in lieu of
all other benefits. **Contact lens benefit provides a $130
yearly allowance towards the exam and purchase of either
conventional or disposable contacts. If lenses and frames
are purchased at the same time only one $25 copay applies.
Over 23,000 frames are covered in full with in-network
providers. Exams, lenses, frame benefits provided once every
12 months. Oklahoma City LasikPlus Traditional Intralase
(bladeless) with a one year plan with insurance discount is
$695 per eye equals $1,390. Traditional Intralase (bladeless)
with a lifetime plan with insurance discount is $1,395 per eye
which equals $2,790. CustomVue Intralase (bladeless) with
a lifetime plan with insurance discount is $1,784.15 which
equals $3,568.30
PVCS: Member must select either in-network or out-of-
nework for entire plan year. In-network services are
unlimited. Out-of-network services (one eye exam, one set of
eyeglasses or contacts) are limited to once annually. A $50.00
service fee applies to all soft contact lens fittings; a $75.00
service fee applies to rigid or gas permeable contact lens
fittings; and a $150.00 service fee applies to hybrid contact
lens fittings. Simple replacements are not assessed with these
fees. Limitations/Exclusions include the following: 1) Medical
eye care, 2) Vision Therapy, 3) Nonroutine vision services
and tests, 4) Luxury frames (wholesale cost of frame is $100
or more), 5) Premium prescription lenses, and
6) non-prescription eyewear. For more information call (888)
357-6912.
United Healthcare: For either glasses or contact lenses there
is one $25 materials copay. In lieu of lenses and frames,
you may select contact lenses. Covered contact lens benefit
includes the fitting/evaluation fees, contact lenses, and up
to two follow-up visits. If covered disposable contact lenses
are chosen, up to six boxes (depending on prescription)
are included when obtained from a network provider. It
is important to note that UHC’s covered contact lenses
may vary by provider. Should you choose contact lenses
outside of the covered selection, a $150 allowance will be
Notes:
COVERED
SERVICES
In-Network Out-of-Network In-Network Out-of-Network
Eye Exams No Copay
No limit to
frequency
Plan pays
up to $40
Limit 1 exam
$10 copay
One exam for
eyeglasses or
contacts every
calendar year
Plan pays up to $35;
One exam every
calendar year
Lenses Per Pair
Member pays
wholesale cost
No limit to number
of pairs
Member pays
normal doctor Fees,
reimbursed up to
$60 for one set of
lenses & frame
annually
$25 Copay for
single/multi-focal
lenses
Plan pays up to:
Single up to $25
Bifocals up to $40
Trifocals up to $60
Lenticular up to
$100
Frames
Member pays
wholesale cost
No limit to number
of frames
Member pays
normal doctor fee
reimbursed up to
$60 for one set of
lenses and frames
annually
$25 Copay, up
to plan limits.
One frame every
calendar year
Plan pays up to $45
Contact Lenses
Member pays
wholesale cost
for annual supply of
contacts
Limit of one set
annually in lieu of
eyeglasses.
Member pays
normal doctor fees
reimbursed up to
$60
**$130 allowance
for conventional or
disposable lenses
and fitting fee in lieu
of all other benefits
every calendar year
Medically necessary,
plan pays 100%
**$130 allowance for
contacts, and fitting
fee in lieu of all
other benefits.
Medically necessary,
plan pays up to $210
Laser Vision
Correction
Discount
nationwide at
The Laser Center
(TLC)
No Benefit
Discount thru TLC,
member will pay no
more than $895 per
eye for conventional
Lasik. See notes
below on Intralase
(bladeless) options.
No Benefit
Humana
www.visioncare.com
PVCS
www.pvcs-usa.com
Lens Options
UV Coating
$11 Copay:
no limit
Member pays
normal doctor Fees
Substantial discount
$15 member cost No Benefit
Tint $11 Copay and up:
no limit
Member pays
normal doctor Fees
Substantial discount
$13 member cost No Benefit
Standard scratch
resist
$13 Copay:
no limit
Member pays
normal doctor Fees
Substantial discount
$16 member cost No Benefit
Standard
Polycarbonate
$50 Copay
and up for SV;
no limit
Member pays
normal doctor Fees
Substantial discount
$30 member cost No Benefit
Standard
Progressive
Wholesale cost,
no limit
Member pays
normal doctor Fees
Substantial discount
$82 member cost
No Benefit
Anti-Reflective $40 and up copay
No Limit
Member pays
normal doctor Fees
Substantial discount
$46 member cost
No Benefit
Oklahoma
Company
2012 Benefits Enrollment Guide 3
applied toward the fitting/evaluation fees and purchase
of contact lenses (materials copay does not apply). Toric,
gas permeable, and bifocal contact lenses are examples of
contact lenses that are outside of our covered contacts.
Necessary contacts are covered-in-full after applicable copay.
Exams, lenses, frame benefits provided once every calendar
year.
Superior: *Materials copay applies to lenses and/or frames.
Discounts for lens add-ons will be given by contracted
providers with a “DP” in their listing. Online, in-network
contact lens materials available at www.svcontacts.com.
Exams, lenses, and frames benefits provided once per
calendar year.
*Progressive Lenses (no-line bifocals) – you will pay the
difference between the retail price of the selected progressive
lens and the retail price of the lined trifocal. The difference
may also be subject to a discount.
Standard contact lens fitting applies to an existing contact
lens user who wears disposable, daily wear, or extended wear
lenses only. The Specialty contact lens fitting applies to a
new contact lens wearers and/or a member who wears toric,
gas permeable or multifocal lenses.
VSP: Exam, lenses and frame benefit provided annually. The
$25 materials copay applies to lenses or frames, but not to
both. Copays/price on premium lens options will vary. If
you choose a frame valued at more than your allowance,
you’ll save 20% on your out-of-pocket costs when you use
a VSP doctor. Contact lenses are in lieu of spectacle lenses
and frames. The $120 in-network allowance applies to the
contact lenses. With a VSP provider, the contact lens exam
(fitting and evaluation) is covered in full after a copay up to
$60. The $105 out-of-network applies to the contacts and
the contact lens exam. Your contact lens exam is performed
in addition to your routine eye exam to check for eye health
risks associated with improper wearing or fitting of contacts.
Prescription glasses - 30% off additional complete pairs of
glasses and sunglasses, including lens options, from the same
VSP doctor on the same day as your WellVision Exam. Or
get 20% off from any VSP doctor within 12 months from
your last WellVision Exam.
$10 Copay
$10 Copay then plan
pays up to
$34 - Ophthalmologist
$26 - Optometrist
$10 Copay Reimbursement
up to $40 $10 Copay $10 Copay then plan
pays up to $35
$25 Copay
Lenses are covered in
full after copay
$25 Copay then plan
pays up to
Single up to $26
Bifocals up to $39
Trifocals up to $49
Lenticular up to $78
$25 Copay
Single up to $40
Bifocals up to $60
Trifocals up to $80
Lenticular up to $80
$25 Copay applies
to lenses or frames.
Single vision, lined
bifocal and trifocal
lenses covered in full.
Average 35% discount
on lens options.
$25 Copay,
then plan pays:
Single up to $25
Bifocals up to $40
Trifocals up to $55
Lenticular up to $80
No Copay
Plan pays up to $120.
Medically necessary
contacts covered in
full. (Contact lens fit
copay: Standard $25, after
copay, covered in full.
Specialty $25, after copay,
plan pays up to $50.)
No Copay
Plan pays up to $100
All Contacts $210
Medically necessary
(Contact lens fit copay:
Standard not covered.
Specialty not covered.)
$25 Copay
On covered-in-full
qualifying lenses
(covers fitting and
evaluation fees,
contact lenses and up to
2 follow-up visits)
(See Notes)
Reimbursement up to
$150 elective contact
lenses,
$210 Medically
necessary contact
lenses
No Copay
Plan pays up to
$120 Conventional
or Disposable.
Medically necessary
contacts covered in full
with prior authorization.
No Copay
Plan pays up to
$105 Conventional
or Disposable,
$210 Medically
necessary
20%-50% Discount
off surgical fees No Benefit
Discount
15 percent off the
usual
& customary
price, 5% off
promotional price
No Benefit
15% average off
usual and customary
price or 5 percent
off the laser center’s
promotional price
No Benefit
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
UnitedHealthcare Vision
Formerly Spectera
www.myuhcvision.com
Superior
www.superiorvision.com
VSP
www.vsp.com
$25 Copay*,
then plan pays up to
$125 retail
Plan pays up to $68 $25 Copay Reimbursement
up to $45
$25 Copay, then plan
pays up to $120
$25 Copay, then plan
pays up to $45
20% discount No Benefit Covered-in-full No Benefit $14 copay No Benefit
20% discount No Benefit Covered-in-full No Benefit $13 - $15 copay No Benefit
20% discount No Benefit Covered-in-full No Benefit $15 copay No Benefit
20% discount No Benefit Available 20-40%
discount No Benefit
Covered in full for dependent
children
$25 - $30 copay for all others
No Benefit
$25 Copay,
*See notes below
Up to $49
*See notes below
Available 20-40%
discount No Benefit $50 copay No Benefit
20% discount No Benefit Available 20-40%
discount No Benefit $39 copay No Benefit
4 2012 Employees Benefits Council of the Office of State Finance
New Login box
Your entry point for
Online Enrollment in the
Benefits Administration
System (BAS) now
looks a little different
(see image at right).
It is in the upper right
corner of the EBC
home page,
www.ebc.ok.gov.
Notice the “Go To”
line, followed by a
drop-down menu.
That is where you
will choose either the new OKHealth Portal or the
Benefits Administration System, which is where you’ll
find Online Enrollment. Your User ID is your six-digit
Employee ID. If you don’t know your password, either
select “Forgot Your Password” or simply select LOGIN
and you will be directed to a screen where you can
update your password.
New Opt-out details
With the approval of House Bill 1062 in May 2011,
state employees were given the right to opt out of state
benefits. Specifically,
“Any active employee eligible to participate or who
is a participant may opt out of the state’s basic
plan as outlined in Sections 1370 and 1371 of Title
74 of the Oklahoma Statutes, provided that the
participant is currently covered by a separate group
health insurance plan. Any active employee eligible
to participate or who is a participant opting out of
coverage pursuant to this section shall provide proof
of the separate health insurance plan participation
and sign an affidavit attesting that the participant
is currently covered and does not require state-provided
health insurance each plan year. Any
active employee opting out of coverage pursuant to
this section shall receive One Hundred Fifty Dollars
($150.00) in lieu of the flexible benefit amount the
employee would be otherwise eligible to receive.”
As the new law spells out, you may opt out ONLY if
you are currently covered by a separate group health
insurance plan. In addition, you must provide proof of
the separate health insurance plan participation and
sign an affidavit before the opt-out will be approved.
You will need to fill out a new form which is available
through your Benefits Coordinator.
The “basic plan” described in the new law consists of
the following: health, dental, basic life and disability
insurance. If you opt out, you are no longer eligible for
any of those coverages through the State. Because
Basic Life insurance is a prerequisite for the optional
Supplemental Life and Dependent Life, those are
eliminated, as well. However, state employees who opt
out can still take advantage of vision insurance offered
by the State, as well as Flexible Spending Accounts
(FSAs).
If you are considering opting out, please understand
you are forfeiting the normal benefit allowance provided
by your agency. In lieu of that benefit allowance, you will
get $150 per month from your agency. That $150 can
be used to pay for vision coverage, FSA contributions,
and/or added to your net pay as taxable income.
Retired Military
State employees who have retired from military service
and have federal TRICARE insurance benefits can also
opt out of the state’s basic plan. Those individuals
will get no coverage for health, dental, life, disability,
supplemental life or dependent life insurance. In lieu of
the normal benefit allowance, TRICARE opt-outs will
receive $150 per month from their agencies. They can
still elect vision coverage as well as flexible spending
account participation. A copy of the participant’s military
service card will be requested as proof of TRICARE
coverage. Employees who go this route must opt out
each year because the election does not roll over.
In response to Senate Bill 623, which also became
law in 2011, your Benefits Office is making a TRICARE
supplement available to military retirees in 2012. See
page 5 for monthly rates and page 6 for biweekly rates.
Benefit Allowance
Your Benefit Allowance Helps
Cover Your Costs The State provides
a Benefit Allowance to help you pay
for insurance premiums that would
otherwise come out of your own
pocket. An estimated 90 percent of
state employees and their families will continue having
100 percent of benefits paid with these dollars. Per
state law, it is calculated using the average of the
highest-cost health plans, the average of the dental
plan premiums, plus the premiums for basic life and
disability. As rates increase, so does your Benefit
Allowance. For employees electing to cover dependents
on health, an allowance is provided to cover 75 percent
of the average of all high option premium dependent
costs.
New login box
2012 Benefits Enrollment Guide 5
Health
CommunityCare: Standard Plan 803.22 1,951.80 2,353.40 2,594.36 1,204.82 1,445.78
CommunityCare: Alternative Plan 553.96 1,346.10 1,623.08 1,789.26 830.94 997.12
CommunityCare: Wellness Alternative Plus 528.96 1,321.10 1,598.08 1,764.26 805.94 972.12
GlobalHealth: Standard Plan 402.84 1,063.56 1,275.83 1,402.00 615.11 741.28
GlobalHealth: Alternative Plan 366.24 966.92 1,159.92 1,274.62 559.24 673.94
GlobalHealth: Wellness Alternative Plus 341.24 941.92 1,134.92 1,249.62 534.24 648.94
United Healthcare Standard Plan 768.80 1,874.16 2,258.28 2,488.88 1,152.92 1,383.52
United Healthcare Alternative Plan 530.20 1,292.52 1,557.42 1,716.46 795.10 954.14
United Healthcare: Wellness Alternative Plus 505.20 1,267.52 1,532.42 1,691.46 770.10 929.14
HealthChoice High 449.48 1,117.58 1,345.78 1,469.66 677.68 801.56
HealthChoice High Alternative 449.48 1,117.58 1,345.78 1,469.66 677.68 801.56
HealthChoice Basic 391.64 963.48 1,165.30 1,274.28 593.46 702.44
HealthChoice Basic Alternative 391.64 963.48 1,165.30 1,274.28 593.46 702.44
HealthChoice USA 688.82 1,377.64 1,603.86 1,726.50 915.04 1,037.68
HealthChoice S-Account 382.56 925.08 1,115.26 1,216.98 572.74 674.46
Tricare Supplement 59.00 118.00 177.00 218.00 118.00 159.00
Dental
Assurant Heritage Plus Dental Plan 11.74 20.60 28.20 35.80 19.34 26.94
Assurant Freedom Preferred Dental Plan 28.83 57.50 79.00 115.30 50.33 86.63
Assurant Heritage Secure Dental Plan 7.20 13.18 18.38 23.56 12.40 17.58
CIGNA Dental 9.26 15.32 22.40 30.64 16.34 24.58
Delta Dental PPO 33.64 67.26 96.52 141.30 62.90 107.68
Delta’s Choice PPO Choice 15.06 49.24 83.68 132.84 49.50 98.66
Delta Dental Premier 38.36 76.72 110.10 161.18 71.74 122.82
HealthChoice Dental 30.20 60.40 85.58 125.72 55.38 95.52
Vision
Humana 6.76 11.82 15.39 16.28 10.33 11.22
Primary Vision Care Services 9.25 17.25 25.75 28.00 17.75 20.00
United HealthCare Vision 8.18 13.97 18.56 20.95 12.77 15.16
Superior Vision Services 7.14 14.24 20.96 28.04 13.86 20.94
Vision Service Plan 8.76 14.63 20.25 27.27 14.38 21.40
Life Insurance Options
Life 4.00 Supplemental Life First Unit 4.00
Disability 9.10
Dependent Life Supplemental Life Age Rated (Per $20,000)
Low Option 2.60 Age
Standard Option 4.32 <30 0.60
Premier Option 8.64 30-34 0.60
35-39 0.80
40-44 1.20
45-49 2.00
50-54 3.40
55-59 5.40
60-64 6.20
65-69 10.20
70-74 17.40
75+ 27.00
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
2012 MONTHLY PLAN RATES
Monthly Benefit Allowance
Employee 640.98
Plus Child 870.89
Plus Children 1,006.19
Plus Spouse 1,312.75
Plus Spouse & 1 Child 1,542.66
Plus Spouse & Children 1,677.96
Monthly
Monthly
6 2012 Employees Benefits Council of the Office of State Finance
Health
CommunityCare: Standard Plan 370.72 900.83 1,086.18 1,197.40 556.07 667.29
CommunityCare: Alternative Plan 255.67 621.27 749.11 825.81 383.51 460.21
CommunityCare: Wellness Alternative Plus 244.14 609.74 737.58 814.28 371.98 448.68
GlobalHealth: Standard Plan 185.93 490.88 588.85 647.08 283.90 342.13
GlobalHealth: Alternative Plan 169.03 446.27 535.35 588.29 258.11 311.05
GlobalHealth: Wellness Alternative Plus 157.50 434.74 523.82 576.76 246.58 299.52
United Healthcare Standard Plan 354.83 865.00 1,042.29 1,148.72 532.12 638.55
United Healthcare Alternative Plan 244.71 596.55 718.81 792.21 366.97 440.37
United Healthcare: Wellness Alternative Plus 233.17 585.01 707.27 780.67 355.43 428.83
HealthChoice High 207.45 515.80 621.12 678.30 312.77 369.95
HealthChoice High Alternative 207.45 515.80 621.12 678.30 312.77 369.95
HealthChoice Basic 180.76 444.69 537.84 588.14 273.91 324.21
HealthChoice Basic Alternative 180.76 444.69 537.84 588.14 273.91 324.21
HealthChoice USA 317.92 635.84 740.25 796.85 422.33 478.93
HealthChoice S-Account 176.57 426.96 514.74 561.68 264.35 311.29
Tricare Supplement 27.23 54.46 81.69 100.61 54.46 73.38
Dental
Assurant Heritage Plus Dental Plan 5.42 9.51 13.02 16.53 8.93 12.44
Assurant Freedom Preferred Dental Plan 13.31 26.54 36.46 53.22 23.23 39.99
Assurant Heritage Secure Dental Plan 3.32 6.08 8.48 10.87 5.72 8.11
CIGNA Dental 4.27 7.07 10.34 14.14 7.54 11.34
Delta Dental PPO 15.53 31.05 44.55 65.22 29.03 49.70
Delta’s Choice PPO Choice 6.95 22.73 38.63 61.31 22.85 45.53
Delta Dental Premier 17.70 35.40 50.81 74.38 33.11 56.68
HealthChoice Dental 13.94 27.88 39.50 58.03 25.56 44.09
Vision
Humana 3.12 5.46 7.11 7.52 4.77 5.18
Primary Vision Care Services 4.27 7.96 11.88 12.92 8.19 9.23
United HealthCare Vision 3.78 6.45 8.57 9.67 5.90 7.00
Superior Vision Services 3.30 6.58 9.68 12.95 6.40 9.67
Vision Service Plan 4.04 6.75 9.34 12.58 6.63 9.87
Life Insurance Options
Life 1.85 Supplemental Life First Unit 1.85
Disability 4.20
Dependent Life Supplemental Life Age Rated (Per $20,000)
Low Option 1.20 Age
Standard Option 1.99 <30 0.28
Premier Option 3.99 30-34 0.28
35-39 0.37
40-44 0.55
45-49 0.92
50-54 1.57
55-59 2.49
60-64 2.86
65-69 4.71
70-74 8.03
75+ 12.46
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
Employee Employee &
Spouse
Employee,
Spouse &
Child
Employee,
Spouse &
Children
Employee &
Child
Employee &
Children
2012 BIWEEKLY PLAN RATES
Biweekly Benefit Allowance
Employee 295.84
Plus Child 401.95
Plus Children 464.40
Plus Spouse 605.89
Plus Spouse & 1 Child 712.00
Plus Spouse & Children 774.45
BIWEEKly
BIWEEKly
2012 Benefits Enrollment Guide 7
Premium Conversion
Do You Want to Save on Your Taxes?
Premium Conversion is an optional, IRS-approved
election chosen by more than
97 percent of state employees, allowing
you to save by paying NO TAX on your
eligible insurance premiums. By paying insurance
premiums for health, dental, vision, flexible spending
accounts and a portion of supplemental life pre-tax, you
have more take-home pay than you would if you paid
the same premiums with after-tax dollars.
The premium conversion option is automatic. You will
be enrolled in premium conversion unless you elect to
opt out. You can opt out of premium conversion in two
ways.
• Select “No” to premium conversion during online
enrollment
• Check the “No” box under the Premium Conversion
section of the paper enrollment form
If you have questions about your premium conversion
options, be sure to ask your Benefits Coordinator.
3 Yes = tax savings!
New Health plans with
discounts!
For the first time, you can get
a discounted premium or lower
deductible on state health insurance!
Now that we have your attention…
Your Benefits Office proudly introduces the “Wellness
Alternative Plus” plans. They are HMO Alternative
plans that cost $25 less per month. As long as you
live or work in a zip code that is serviced by one of the
state’s three HMOs, the only thing you have to do to
get the discounted premium is complete a Health Risk
Assessment (HRA). You’ll find it in the OKHealth section
of www.ebc.ok.gov. It only takes a few minutes to fill
out, and in return, you’ll save $300 during 2012. The
discount is available to all state employees, including
current and former OKHealth participants; however, a
new HRA is required.
You have until November 10th to complete the HRA.
If you choose a Wellness Alternative Plus plan, but
don’t complete the HRA by November 10th, you will
be defaulted into that company’s Alternative plan,
which has a higher rate.
Wellness Alternative Plus plans are offered by each of
the available HMOs: CommunityCare, GlobalHealth
and UnitedHealthcare. It is important to note: the
discounted rates for the new plans were not attained by
increasing premiums on other plans. Best-and-final-offer
rates for the HMO Standard and Alternative plans did
not change after the new plans were requested. Your
Benefits Office negotiated the $25/month discounts by
emphasizing that wellness program participants typically
have lower utilization of health care and are, therefore,
less expensive to insure. The private-sector health plans
agreed and support the initiative to improve the overall
health of state employees. Check your zip code by
going to the EBC web site, www.ebc.ok.gov, go to the
Benefits section and select “Provider Directory.” Select
your zip code from the drop-down list. If it’s not on the
list, please check with your Benefits Coordinators to
check HMO availability in your area.
Most HealthChoice members have opportunities to
save, as well. State employees who don’t smoke or
use other tobacco products will continue to have
a HealthChoice High annual deductible of $500
(individual) or $1,500 (family). Otherwise, the calendar
year deductibles will be $750 or $2,250. In addition,
HealthChoice members can complete the H.E.L.P.
Health Risk Assessment as well as the biometric
requirements and receive $100. Look for the HRA
link on the home page of www.sib.ok.gov or www.
healthchoiceok.com.
HealthChoice Health Plans
• Each year, tobacco use costs the HealthChoice
health plans and their members approximately $52
million. Because these costs affect the premiums of
all health plan members, HealthChoice is encouraging
members to stay or become tobacco free by freezing
the deductible and out-of-pocket limits of the
HealthChoice High and Basic Plans at 2011 amounts
for non-tobacco users. The HealthChoice High
Alternative and HealthChoice Basic Alternative Plans
are being introduced for tobacco users. The individual
deductibles and out-of-pocket limits for these two
plans are $250 higher than the High and Basic Plans.
To enroll or remain enrolled in the HealthChoice High
or Basic Plan for Plan Year 2012, you must attest that
you and your covered dependents are tobacco-free
by completing the HealthChoice High and Basic Plans
Tobacco-Free Attestation for Plan Year 2012 by October
28, 2011. The attestation is available to you:
• Online at www.sib.ok.gov or
www.healthchoiceok.com
• From your Benefits Coordinator
• By calling HealthChoice Member Services at
1-405-717-8780 or toll-free 1-800-752-9475.
TDD users call 1-405-949-2281 or toll-free
1-866-447-0436.
If you cannot complete the tobacco-free attestation
because you and/or your covered dependents are not
tobacco-free, you can still qualify for the HealthChoice
High or HealthChoice Basic plan if you can show proof
of an attempt to quit using tobacco or provide a letter
from your doctor. To qualify for the tobacco-free plans,
you must provide one of the following:
(continued on page 8)
8 2012 Employees Benefits Council of the Office of State Finance
• A letter indicating you and/or your covered
dependents have enrolled in the quit tobacco program
available through the Oklahoma Tobacco Settlement
Endowment Trust (TSET) and Alere Wellbeing within
the previous 90 days.
• A letter indicating you and/or your covered
dependents have completed the quit tobacco
program available through the Oklahoma Tobacco
Settlement Endowment Trust (TSET) and Alere
Wellbeing within the previous 90 days.
• A letter from your doctor indicating it is not medically
advisable for you or your covered dependents to quit
tobacco.
The letter from TSET or your doctor must be provided
to HealthChoice at 3545 N.W. 58 Street, Suite 110,
Oklahoma City, OK 73112 by October 28, 2011. If you
do not or cannot complete the tobacco-free attestation
or provide one of the letters described previously,
you and your covered dependents will be enrolled
in the new HealthChoice High Alternative Plan or
HealthChoice Basic Alternative Plan.
HealthChoice High, High Alternative, Basic, Basic
Alternative, S-Account, and USA Plans
• No limit on visits and treatment days for mental health
and substance abuse, certification required.
• Non-Network emergency room visits will be covered
at the Network benefit level; however, you can still
be billed for non-covered services and amounts over
Allowed Charges.
• Preventive Procedures Covered at 100% of
Allowed Charges. As an enhanced benefit for
HealthChoice members, preventive procedures and
many other services will be covered at 100% of
Allowed Charges with no out-of-pocket costs when
using a Network Provider. This means no-cost access
to such services as:
• Blood pressure, diabetes, and cholesterol
tests
• Breast, cervical, prostate, and colorectal
cancer screenings
• Osteoporosis screening
• Counseling from your health care provider
on topics including quitting tobacco, losing
weight, eating healthy, treating depression,
and reducing alcohol use
• Prescription tobacco cessation products
• Vaccines for children and adults
• Flu and pneumonia shots
• Screening for obesity and counseling from
your doctor and other health professionals
to promote sustained weight loss, including
dietary counseling from your doctor
• Screening for conditions that can harm
pregnant women or their babies, including iron
deficiency, hepatitis B, a pregnancy related
immune condition called Rh incompatibility,
and a bacterial infection called bacteriuria
• Special pregnancy-tailored counseling from a
doctor to help pregnant women quit smoking
and avoid alcohol use
• Counseling to support breast-feeding and help
nursing mothers
See the HealthChoice website at www.sib.ok.gov or
www.healthchoiceok.com for more details.
HealthChoice High, High Alternative, and USA Plans
• HealthChoice is implementing a family out-of-pocket
limit for the HealthChoice High, High Alternative and
USA Plans. The family out-of-pocket limit for the High
and USA Plans will be $8,400 when using a Network
Provider and $9,900 when using a non-Network
Provider. The family out-of-pocket limit for the High
Alternative Plan will be $9,150 when using a Network
Provider and $10,650 when using a non-Network
provider.
HealthChoice S-Account Plan
• The out-of-pocket limits are being lowered to
$3,000/individual and $6,000/family.
• Proof of a Health Savings Account (HSA) is not
required to enroll.
• HealthChoice has contracted with American Fidelity
Health Services Administration to make establishing
and keeping a Health Savings Account easier and
more convenient for S-Account members. See the
Health Savings Accounts information page in the back
pocket of this guide.
HealthChoice Pharmacy Benefit
• Two 90-day courses of prescription tobacco cessation
products will be covered at 100% with no cost to
members.
• HealthChoice is introducing a mail order pharmacy
benefit and changing the quantity of medication
members can get per copay. A 30-day supply of
medication will be covered when purchased at a
retail pharmacy for one copay. A 90-day supply of
maintenance medication will be covered for one
copay when purchased through Medco’s mail order
service or one of the Network Retail Maintenance
Pharmacies. See the Health Plan Comparison for
copay amounts.
2012 Benefits Enrollment Guide 9
2012
Health
Plans
Comparison
Chart
Active and New Employees
of the State of Oklahoma
10 2012 Employees Benefits Council of the Office of State Finance
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
Choice of Provider
Calendar Year Deductible
Annual Out-of-Pocket
Maximum
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP
on Enrollment Form)
PCP referral & HMO
authorization required for
some care received
outside PCP office.
None
Individual: $2,500
Family: $5,000
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP on
Enrollment Form)
However, no referral
for your contracted
specialist when the
specialist is in
UnitedHealthcare’s
SignatureValue HMO
network (referral
required for behavioral
health and chiropractic
providers)
None
Individual: $2,500
Family: $5,000
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP
on Enrollment Form)
Members may
self-refer to most
specialists for initial
visit.
None
Individual: $3,000
Family: $6,000
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Contact your PCP for
all medical care (New
Hires & New Enrollees
must indicate PCP
on Enrollment Form)
PCP referral & HMO
authorization required
for all care received
outside PCP office. You
may self-refer to an
in-network OB/GYN.
For children, you may
designate a pediatrician
as the primary care
provider.
None
Individual: $3,000
Family: $5,000
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 11
Choice of Network Provider for
medically necessary services
$30 Physician
$50 Specialist
Physicians include;
General Practitioners
Internal Medicine Physicians
OB/GYNs
Pediatricians
Physician Assistants
Nurse Practioners
High
Individual: $500
Family: $1,500
High Alternative
Individual: $750
Family: $2,250
See Emergency
Health Care for additional per
service deductible.
High
Individual: $2,800
Family: $8,400
(includes deductible)
High Alternative
Individual: $3,050
Family: $9,150
(includes deductible)
Non-covered services,
copays & ER deductible
do not apply
Choice of any Provider,
Allowed Charges for medically
necessary services. Member
responsible for amount that
exceeds the Allowed Charges
when using a non-Network
provider and all ineligible
expenses.
High
Individual: $500
Family: $1,500 plus $300
per confinement hospital
deductible.
High Alternative
Individual: $750
Family: $2,250 plus $300
per confinement hospital
deductible.
See Emergency Health
Care and Hospital Inpatient
for additional per service
deductible.
High
Individual: $3,300
Family: $9,900
(includes deductible)
High Alternative
Individual: $3,550
Family: $10,650
(includes deductible)
plus Member is
responsible for
amount that exceeds
the Allowed Charges,
inpatient deductible, ER
deductible & charges over
maximum benefit limitations
Choice of any Provider,
Allowed Charges for
medically necessary
services. Member
responsible for amount
that exceeds the Allowed
Charges when using a non-
Network provider and all
ineligible expenses.
Basic
Individual: $500
Family: $1,500 Deductible
applies after Plan pays first
$500 of Allowed Charges.
Basic Alternative
Individual: $750
Family: $1,500
Deductible applies after
Plan pays first $250 of
Allowed Charges. Plan
offers same benefits and
unlimited lifetime maximum
on eligible health and
pharmacy benefits as the
HealthChoice High Plan.
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Choice of Provider for
medically necessary
services
Individual: $1,500
Family: $3,000
The combined medical
and pharmacy deductible
must be met before
benefits are paid.
Individual: $3,000
Family: $6,000
Non-Network charges do
not apply.
HealthChoice
High & High Alternative
Network
A reduced benefit level and additional
out-of-pocket costs apply when using a
non-Network provider
HealthChoice
High & High Alternative
Non-Network
A reduced benefit level and additional
out-of-pocket costs apply when using a
non-Network provider
HealthChoice
Basic &
Basic Alternative
Additional out-of-pocket costs apply
when using a non-Network provider
HealthChoice
S-Account
Network*
A reduced benefit level and additional
out-of-pocket costs apply when using
a non-Network provider
12 2012 Employees Benefits Council of the Office of State Finance
Office Visits
(Professional Services)
Prescription Drugs
Copayments
$30 PCP
$40 Specialist per visit
$5/$30/$60
30 day supply
Selected medications
may have restricted
quantities.
Copays
$35 PCP
$50 Specialist
$5 copay for
formulary generic
drug
$30 copay for
formulary brand
name drug
$60 non-formulary
generic and brand
drug
The lesser of 30-day
supply or 100 units;
certain medications
have restricted
quantities
******************
Contraceptive Drugs:
$5 copay for
formulary generic
drug
$30 copay for
formulary brand
name drug
$60 non-formulary
generic and brand
drug
The lesser of 30-day
supply or 100 units;
certain medications
have restricted
quantities
Copays
$35 PCP copay per
visit
$50 Specialist copay
per visit
Up to $0 select generic
formulary
Up to $10 generic
formulary
Up to $40 brand
formulary
(when no generic is
available)
Up to $65 brand
formulary
(when generic is
available)
Up to $65 non
formulary
30-day supply
Selected medications
may have restricted
quantities.
Convenience Mail
Order Pharmacy
Up to 90 day supply
for 3 copays
Copayments
$25 PCP
$50 Specialist
$10/$50/$75
Includes a 1 month
supply
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 13
$30 Physician copay; $50
Specialist copay per office visit;
for other professional services,
the calendar year deductible
applies first; member pays 20%
of Allowed Charges
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum of
$10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands - Cost
of medication is up to $60, or a
maximum of $120
Mail Delivery and
Retail Maintenance
Pharmacies – 90 day supply:
Preferred Generic – Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60.
Non-Preferred Brand - Cost
of medication up to $60 or a
maximum copay of $120.
Specialty Medication Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per 30-
day supply
Brand/Generic difference:
Member is responsible for the
difference in the brand and
generic if a brand is purchased
when a generic is available. For
more details visit
www.healthchoiceok.com or
www.sib.ok.gov
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount that exceeds
the Allowed Charges and all
ineligible expenses
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum
of $10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands - Cost
of medication is up to $60, or a
maximum of $120
Mail Delivery and Retail
Maintenance Pharmacies – 90
day supply:
Preferred Generic –Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60.
Non-Preferred Brand - Cost
of medication up to $60 or a
maximum copay of $120.
Specialty Medication Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per 30-
day supply
Brand/Generic difference:
Member is responsible for the
difference in the brand and
generic if a brand is purchased
when a generic is available. For
more details visit
www.healthchoiceok.com or
www.sib.ok.gov
Once a Member spends
$5,500/$5,750 out-of pocket,
the Basic Plan will pay 100%
of all other Allowed Charges
for that Plan Year. Family
deductible is $1,000/$1,500
w/a maximum annual
family out-of-pocket of
$11,000/$11,500
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum
of $10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands -
Cost of medication is up to
$60, or a maximum of $120
Mail Delivery and Retail
Maintenance Pharmacies –
90 day supply:
Preferred Generic –Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60. Non-
Preferred Brand - Cost of
medication up to $60 or a
maximum copay of $120.
Specialty Medication
Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per
30-day supply
Brand/Generic difference:
Member is responsible for
the difference in the brand
and generic if a brand is
purchased when a generic
is available. For more details
visit
www.healthchoiceok.com or
www.sib.ok.gov
After the calendar year
deductible, $50 copay
After the $1,500 individual
or $3,000 family deductible
has been met, the pharmacy
benefits are:
Retail-30 day supply
(Including first 3 fills of
maintenance medications)
Preferred Generic - Cost of
medication up to a maximum
of $10;
Preferred Brand – Cost
of medication up to $15 or
maximum copay of $30.
Non-Preferred Brands -
Cost of medication is up to
$60, or a maximum of $120
Mail Delivery and Retail
Maintenance Pharmacies –
90 day supply:
Preferred Generic –Cost of
medication up to maximum
copay of $25.
Preferred Brand – Cost
of medication up to $30 or
maximum copy of $60.
Non-Preferred Brand - Cost
of medication up to $60 or a
maximum copay of $120.
Specialty Medication
Copay:
Preferred - $60 per 30-day
supply
Non-Preferred - $120 per
30-day supply
Brand/Generic difference:
Member is responsible for
the difference in the brand
and generic if a brand is
purchased when a generic
is available. For more details
visit
www.healthchoiceok.com or
www.sib.ok.gov
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
14 2012 Employees Benefits Council of the Office of State Finance
No charge one time
per plan year for
PCP visits, biometric
measurements and
lab work as specified
by OK Health
Program. If any other
services are provided
during PCP office
visit, member will be
charged an office
copay and other
appropriate charges
$500 copay per
admission
(prior authorization
from PCP required)
$300 copay per visit
outpatient surgical
facility
$200 per visit copay
(waived if admitted)
$50 copay per visit
(prior authorization
required)
No charge one time per
plan year for PCP visits,
biometric measurements
and lab work as
specified by OK Health
Program
$250 copayment per
inpatient day
$750 max. per
admission
Precertification from
PCP required
$250 copayment per
visit
As authorized by PCP
$150 per visit
copayment
(waived if admitted)
$25 PCP/$50 all other
providers
NOTE: Must use in-network
facilities.
No charge one time
per plan year for
PCP visits biometric
measurements and
lab work related
to the OK Health
Program.
If any other services
are provided during
this PCP office visit,
member will be
charged an Office
Visit copay.
$1,000 Copay per
admit
$500 copay per
Outpatient Surgery
visit
$200 copay per visit
(waived if admitted
as an
inpatient from
emergency room)
$50 copay per visit
No charge one time per
plan year for PCP visits,
biometric measurements
and lab work as
specified by OK Health
Program. If any other
services are provided
during this PCP office
visit, member will
be charged office
visit copay and other
appropriate charges.
$350 per admission
$250 per visit
$150 per visit
(waived if admitted)
$40 per visit
OKHealth Program
(Only for State employees
participating in OKHealth
Program, dependents do
not qualify.)
Hospital Inpatient
Hospital Outpatient
Emergency Health Care
After Hours Urgent Care
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 15
One free initial doctor’s office
visit related to OK Health
Program requirements.
One free fasting lipid
(Cholesterol/
triglycerides) profile
One fasting glucose (sugar) test
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar year
deductible.
Certification required
for certain outpatient
surgeries
Member pays 20% of Allowed
Charges after the calendar year
deductible.
$100 ER deductible; waived if
hospitalized
Member pays 20% of
Allowed Charges after the
calendar year deductible
Not covered for
non-Network
Member pays 50% of
Allowed Charges after
the calendar year deductible
and $300 per confinement
hospital deductible, plus
amount that exceeds the
Allowed Charges and
all ineligible expenses.
Certification
required
Member pays 50% of
Allowed Charges after the
calendar year deductible,
plus amount that exceeds
the Allowed Charges and
all ineligible expenses.
Certification
required for certain
outpatient surgeries
Member pays 20% of
Allowed Charges after the
calendar year deductible,
plus amount that exceeds the
allowed charges.
$100 ER deductible; waived if
hospitalized
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
One free initial Network
provider’s office visit related
to OK Health Program
requirements.
One free fasting lipid
(Cholesterol/
triglycerides) profile, one
fasting glucose (sugar) test
HealthChoice Basic plan
offers the same benefits
as the HealthChoice High
(Network) Plan
Using Network providers will
maximize your benefits.
Certification required
The $100 ER deductible
does not apply to the Basic
and Basic Alternative Plans
Basic Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
One free initial doctor’s
office visit related to
OK Health Program
requirements.
One free fasting lipid
(Cholesterol/
triglycerides) profile
One fasting glucose (sugar)
test
Member pays 20% of
Allowed Charges after
the calendar year deductible
and $300 per confinement
hospital deductible when
using a non-Network
provider plus amount
that exceeds the Allowed
Charges and all ineligible
expenses
Certification required
Member pays 20% of
Allowed Charges
after the calendar year
deductible.
Certification required for
certain outpatient surgeries
Member pays 20%
of Allowed Charges
after the calendar year
deductible.$100 ER
deductible; waived if
hospitalized
Member pays 20% of
Allowed Charges after the
calendar year deductible
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
16 2012 Employees Benefits Council of the Office of State Finance
Diagnostic X-ray and Lab
Allergy Treatment And
Testing
Well-child Care
Immunizations
Maternity
No additional
copayment for
Laboratory services or
Outpatient Radiology
$150 copayment per
scan for MRI, CT, MRA
and PET Scan
$30 per visit to PCP
$40 per visit to
Specialist
$30 for Allergy Serum
and shots, including (6)
six week supply Antigen
and administration
No Charge
No Charge (Ages birth
– 18)
No Charge (Ages 19 and
over)
$30 for initial visit
$350 per admission
No additional copay for
Laboratory services or
Outpatient Radiology.
$200 copay per scan
for MRI, CT, MRA and
PET Scan
$35 copay per visit to
PCP
$50 copay per visit to
Specialist
$30 copay for Allergy
Serum (six week
supply - including
shots)
No copay
No copay for childhood
immunizations up to 18
No copay for
medically necessary
immunizations 19 and
over
$35 copay for initial visit
only (includes prenatal
and postnatal care)
No copay for Prenatal
Classes
Amniocentesis (medically
necessary; outpatient
surgical facility copay
may apply)
$500 per admission
No additional
copayment for
Laboratory services or
Outpatient Radiology
$250 copayment per
scan for MRI, CT, MRA
and PET Scan
$25 PCP /$50 Specialist
$30 copayment per
6 weeks antigen and
shots
No Copayment up to
age 21
No copayment
Office copayments may
apply
$25 physician services
copayment for initial
visit only
$250 copayment per
day hospital admission
$750 max. per
admission
Standard Laboratory
and Radiology: $0
copay
Specialized scanning
and imaging (MRI,
MRA, PET, CAT,
Nuclear Scans): $200
copay per scan
$35 PCP
$50 Specialist
$35 Serum and shots
including a six
(6) week supply
of antigen and
administration
No copay
No copay (if no other
service is rendered)
In accordance with
the US Preventive
Services Task Force
and other health
organizations required
guidelines.
$35 PCP
$50 Specialist. copay
for initial visit once
diagnosis of
pregnancy
is confirmed;
$1,000 copay
per admit for
Hospitalization
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 17
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Limit: Battery of 60 tests
every 24 months
$0 copay for preventive well
baby exam
Well-baby and adult
immunizations covered
at 100%, $50 copay per
specialist office visit.
Administration charge may
apply
$30 Physician
$50 Specialist
Physicians include; General
Practitioners, Internal
Medicine Physicians,
OB/GYN, Pediatricians,
Physicians Assistants, Nurse
Practioners
Member pays 20% of
Allowed Charges after the
calendar
year deductible
Includes one postpartum
home visit (must meet
criteria)
Also see Hospital
Inpatient Benefits
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount that exceeds
the Allowed Charges and all
ineligible expenses
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount that exceeds
the Allowed Charges and all
ineligible expenses
Limit: Battery of 60
tests every 24 months
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
Member pays 50% of Allowed
Charges after the calendar
year deductible and $300
per confinement hospital
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Includes one postpartum home
visit (must meet criteria) Also
see Hospital
Inpatient Benefits
Basic Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Limit: Battery of 60 tests
every 24 months
$0 Copay for preventative
well-baby exam
Well-baby & Adult
immunizations covered at
100%
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of
Allowed Charges after the
calendar year deductible
Limit: Battery of 60 tests
every 24 months
$0 copay for preventive well
baby exam
Well-baby and adult
immunizations covered at
100%. Office visit is subject
to $50 copay. Administration
charge is subject to
deductible and coinsurance
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Includes one postpartum
home visit (must meet
criteria)
Also see Hospital
Inpatient Benefits
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
Contraceptive Services
Contraceptive Drugs
Infertility Services
Mental Health Inpatient
Mental Health Outpatient
Including Gambling
Addiction
$30 PCP
$40 Specialist
per visit for consultation
$30 PCP/$40 Specialist
for surgical procedure
Tier 1: $ 5
Tier 2: $30
Tier 3: $60
30 day supply
Selected medications
may have
restricted quantities.
One copay per
injectable contraceptive
25% of cost + office
visit copayment –
includes diagnosis
and some treatment
including drug treatment
$30 PCP/$40 Specialist
$350 Inpatient
No limit on treatment
days
$30 PCP
No limits on visits
$35 PCP/$50
Specialist
copay per visit for
consultation
$35 PCP/$50
Specialist copay for
surgical procedure (in
office)
See Prescription Drug
Benefits
Up to $0 select generic
formulary
Up to $10 generic
formulary
Up to $40 brand
formulary (when no
generic is available)
Up to $65 brand
formulary (when generic
is available)
Up to $65 non formulary
30-day supply
Selected medications
may have restricted
quantities. One
copay per injectable
contraceptive.
$35 PCP copay per
visit
$50 Specialist copay
per visit. Office
visit copays apply.
Infertility Services
50% Copay. Infertility
Medications (require
prior authorization)
are subject to a 50%
copay
$500 copay per
admission (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$35 PCP copay per
visit
$50 Specialist copay
per visit (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$50 copayment for
services performed in
office setting
Covered under
prescription drug benefit
Tier 1: $4/$10
Tier 2: $50
Tier 3: $75
50% coinsurance,
office visit copayments
apply
$250 per inpatient day
copayment
($750 max. per
admission)
Must be preauthorized
$25 copayment per visit
Must be preauthorized
Consultation, $35
PCP copay
$50 Specialist copay
$35PCP/$50
Specialist
Surgical Procedure
If Outpatient surgery
$500 copay
Please refer to
prescription drug
benefit; $50 copay
for Depo-Provera
Injection
25% of Total Charges
(Basic Services)
25% cost plus copay
$35 PCP
$50 Specialist
$1,000 copay per
admission
$35 PCP
18 2012 Employees Benefits Council of the Office of State Finance
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
Member pays 20% of
Allowed Charges after the
calendar year deductible
See Prescription Drugs.
Member pays 20% of
Allowed Charges after the
calendar year deductible
Benefits available for diagnosis
and some treatment.
See exclusions in member
materials
Member pays 20% of
Allowed Charges after the
calendar year deductible
Certification required
Member pays 20% of Allowed
Charges after calendar
year deductible. Requires
certification after 15 visits or
penalty will apply.
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses
See Prescription Drugs.
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds Allowed Charges and
all ineligible expenses. Benefits
available for diagnosis and some
treatment. See exclusions in
member materials.
Member pays 50% of
Allowed Charges after the
calendar year deductible plus
$300 per confinement deductible,
plus amount that exceeds
Allowed Charges and all ineligible
expenses. Certification required
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Requires certification after 15
visits or penalty will apply.
See Prescription Drugs
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Member pays 20% of Allowed
Charges after the calendar
year deductible
After the $1,500 individual
or $3,000 family deductible
has been met, all Pharmacy
copays apply. See
Prescription Drugs.
Member pays 20% of Allowed
Charges after the calendar
year deductible
Benefits available for
diagnosis and some
treatment.
See exclusions in member
materials
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar
year deductible. Requires
certification after 15 visits or
penalty will apply.
2012 Benefits Enrollment Guide 19
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
20 2012 Employees Benefits Council of the Office of State Finance
Substance Abuse
Inpatient
Substance Abuse
Outpatient
Hearing Screening
Hearing Aids
Physical, Occupational,
or Speech Therapy
$350 Inpatient
No limit on treatment
days
$30 PCP
$40 Specialist
No limit on visits
No charge ages 0 to 21
Hearing Screening Adult
One (1) visit per year
$30
Not covered except for
children up to 18 years
of age: audiological
services and hearing
aids are covered
(as durable medical
equipment)
Limited 1 hearing
aid per ear every 48
months.
No Charge for Inpatient
care
(limited to sixty (60)
treatment days per
course of therapy).
Outpatient is $30
PCP/$40 Specialist
$500 copay per
admission (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$35 copay per visit
PCP
$50 copay per visit
specialist (requires
preauthorization and
approval through
CCOK Behavioral
Health Services)
$0 copay per
visit(covered under
preventive care
services and limited to
one per year)
20% copay for children
up to age 18.
Coverage shall only
apply to hearing aids
that are prescribed,
filled and dispensed by
a licensed audiologist,
and may limit the
hearing aid benefit
payable for each
hearing-impaired ear
to every forty-eight
(48) months; provided,
however, such coverage
may provide for up
to four (4) additional
ear molds per year for
children up to two (2)
years of age.
No copay for Inpatient
Rehabilitation
$50 copay for
Outpatient Physical,
Occupational or
Speech Therapy (up to
60 treatment days per
disability)
$250 per inpatient day
copayment
$750 max. per
admission
Must be preauthorized
$25 copayment per
visit
Must be preauthorized
No copayment per visit
up to age 21
$25 copayment per
visit age 22 and over
limited to 1 per year
Covered for children up
to age 18 only
20% coinsurance
No copayment for
inpatient rehabilitation
$50 Specialist
copayment per visit for
outpatient
Limited to 60 days per
illness or injury
$1,000 copay per
admission
$35 PCP
$0 PCP copay per visit
No Charge (Ages 0-17)
20% coinsurance for
adults age 18 and
over. Limited to a
single hearing aid every
3 years. Maximum
benefit of $5,000 per
calendar year.
Inpatient: No Charge
Outpatient: $35 PCP
$50 Specialist copay
per visit
Combined limit of 60
treatment days per
medical episode
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 21
Member pays 20% of
Allowed Charges after the
calendar year deductible
Certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Requires certification after 15
visits or penalty will apply
$30 Physician copay,$50
Specialist copay per office
visit for a
basic hearing screening
only (does not include a
comprehensive hearing exam)
One per calendar year
*See Choice of Provider
Benefit limited to
children up to age 18;
audiological services and
hearing aids are covered as
Durable Medical Equipment.
No benefits for ages 18 and
over; certification
required
Member pays 20% of Allowed
Charges after calendar year
deductible.
Certification required after 20
visits.
Each service limited to 60
visits per year
Member pays 50% of Allowed
Charges after the calendar
year deductible and $300 per
confinement hospital deductible,
plus amount above the Allowed
Charges and all ineligible
expenses.
Certification required
Member pays 50% of
Allowed Charges after the
calendar year deductible, plus
amount that exceeds the Allowed
Charges & all ineligible expenses.
Requires certification after 15
visits or penalty will apply
Member pays 50% of Allowed
Charges after the calendar year
deductible, plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Basic hearing screening only
Benefit limited to children up to
age 18; audiological services
and hearing aids are covered as
Durable Medical Equipment.
No benefits for ages 18 and over;
certification required
Member pays 50% of Allowed
Charges after calendar year
deductible plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Certification required after 20
visits. Each service limited to 60
visits per year
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Member pays 20% of
Allowed Charges after the
calendar year deductible
Certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Requires certification after
15 visits or penalty will apply
$50 copay per visit after the
calendar year deductible for
a basic hearing screening
(does not include a
comprehensive hearing
exam)
One per calendar year
Benefit limited to
children up to age 18;
audiological services and
hearing aids are covered as
Durable Medical Equipment.
No benefits for ages 18 and
over; certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required after 20
visits.
Each service limited to 60
visits per year
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
22 2012 Employees Benefits Council of the Office of State Finance
Chiropractic &
Manipulative Therapy
Durable Medical
Equipment (DME)
Blood and Blood
products
Skilled Nursing Facility
Periodic Health Exams
$40 Specialist per visit
limited to 15 visits per
calendar year
20% for initial
device/20% for repair and
replacement
No Charge
No Charge
No Charge
$50 copay per visit
(15 visits per year)
(PCP prior
authorization
required)
20% copay
(prior authorization
required)
No copay
No copay
(Limit: Max 100 days
per year)
$0 copay
Routine Physicals
$50 copayment per
visit
Must be preauthorized
20% coinsurance
No copayment
Limit: 100 days per
Plan Year
$250/day copayment
$750 max. per
admission
No copayment per
PCP limited to 1 per
year
$50 Specialist copay
per visit;
15 visits per calendar
year,
limited to treatments of
neurological and
orthopedic conditions
(Referral required)
20% coinsurance
Applies Autologous,
donor directed, and
donor designated blood
processing costs are
limited to $120 per
unit and must be for a
scheduled procedure
$1,000 copay per
admission;
Limited to 100
consecutive days/
calendar year
$0 PCP copay per visit
$50 Specialist copay
per Visit
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 23
Member pays 20%
of Allowed Charges after
calendar year deductible
Certification required after 20
visits. Each service limited to
60 visits per year
Member pays 20% of
Allowed Charges after the
calendar year deductible for
covered items.
Purchase, rental, repair, or
replacement must be certified
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of Allowed
Charges after
the calendar year deductible.
Certification required
Limit: 100 days per year
$0 copay for one preventive
services visit per calendar
year for members and
dependents age 20 and older.
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
One mammogram per year at
no charge for woman age 40
and older. For woman under
age 40, $30 Physician copay
or $50 Specialist copay per
office visit. Some guidelines
apply
*See Choice of Provider
Member pays 50% of Allowed
Charges after calendar year
deductible plus amount that
exceeds the Allowed Charges
and all ineligible expenses.
Certification required after 20
visits.
Each service limited to 60
visits per year
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Purchase, rental, repair, or
replacement must be certified
Member pays 50% of
Allowed Charges after
the calendar year deductible,
plus amount above Allowed
Charges and all ineligible
expenses
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required
Limit: 100 days per year
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
No copay or deductible
for one mammogram per
calendar year for women age
40 and over, member pays
charges over $115. Some
guidelines apply
One preventive services
visit covered at 100%
of Allowed Charges for
members and dependents
age 20 and older. H.E.L.P.
Check program pays primary
member $100 for completing
preventive services visit,
metabolic and lipid panels,
and health risk assessment.
Member pays 20% of Allowed
Charges after the calendar
year deductible
Certification required after 20
visits. Each service limited to
60 visits per year
Member pays 20% of Allowed
Charges after the calendar
year deductible for covered
items. Purchase, rental,
repair, or replacement must be
certified
Member pays 20% of
Allowed Charges after the
calendar year deductible
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Limit: 100 days per year
$0 copay for one preventive
services visit per calendar
year for members and
dependents age 20 and older.
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
One mammogram per year at
no charge for woman age 40
and older. For woman under
age 40, $30 Physician copay
or $50 Specialist copay per
office visit. Some guidelines
apply
*See Choice of Provider
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
24 2012 Employees Benefits Council of the Office of State Finance
Temporomandibular Joint
(TMD) Dysfunction
Home Health Services
Medical Transportation
Transplants
Hospice
Preventive Services
Eye Care
$50 per treatment plan
Lifetime non-surgical
maximum of
$1,500
Surgery is under medical
No Charge
No Charge
No Charge
No Charge
$100 copay per
treatment plan
(lifetime non-surgical
maximum of $1,500)
No copay
(prior authorization
required)
Ambulance No copay
(must have prior
authorization except
for emergencies)
No copay (all
transplant
services, including
evaluations must be
preauthorized)
No copay
$10 copay
Vision Screening and
Refraction (one every
365 days) Contact
Members Services for
a contracted provider
$100 copayment per
treatment plan
NOTE: Lifetime
non-surgical maximum
of $1,500. Surgical is
under medical.
$25 copayment per
visit
Must be prescribed by
PCP
$100 copayment
Inpatient copayment
applies
Preapproval and
precertification
required
No copayment
for terminal illness
of six months or less
Preapproval required
$50 copay,
$1,500 lifetime
maximum for
nonsurgical benefits
$50 copay per visit
No Charge
Non-emergency
transportation requires
prior authorization.
$1,000 per admit
$50 copay per visit
Health Plans
Comparison Chart
Active and New
Employees of the
State of Oklahoma
HMO Standard Plan
CommunityCare
GlobalHealth
UnitedHealthcare
UnitedHealthcare
HMO
Alternative
and Wellness
Alternative Plus
CommunityCare
HMO
Alternative
and Wellness
Alternative Plus
GlobalHealth
HMO
Alternative
and Wellness
Alternative Plus
Oklahoma
Company
Oklahoma
Company
2012 Benefits Enrollment Guide 25
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Limit: 100 visits per calendar
year
Member pays 20% of Allowed
Charges after the calendar
year deductible.
If not an emergency,
medically necessary services
require certification
Member pays 20% of Allowed
Charges after the calendar
year deductible.
Certification required
Member pays 20% of Allowed
Charges after the calendar
year deductible. For life
expectancy of six months or
less
Certification is required
Age 20 and older, no charge
one time per calendar
year for preventive service
visit, metabolic panel, and
comprehensive lipid panel
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required Limit:
100 visits per calendar year
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
If not an emergency, medically
necessary services require
certification
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses.
Certification required
Member pays 50% of Allowed
Charges after the calendar
year deductible, plus amount
above Allowed Charges and
all ineligible expenses. For life
expectancy of six months or
less Certification is required
Member pays 50% of Allowed
Charges after the individual
calendar year deductible,
plus amount above Allowed
Charges and all ineligible
expenses
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Basic
Individual: $5,500
Family: $11,000
Basic Alternative
Individual: $5,750
Family: $11,500
Age 20 and older, no charge
one time per calendar
year for preventive service
visit, metabolic panel, and
comprehensive lipid panel
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
Member pays 20% of
Allowed Charges after the
calendar year deductible.
Certification required
Member pays 20% of
Allowed Charges after
the calendar year deductible.
Certification required Limit:
100 visits per calendar year
Member pays 20% of
Allowed Charges after the
calendar year deductible.
If not an emergency,
medically necessary services
require certification
Member pays 20% of
Allowed Charges
after the calendar year
deductible.
Certification required
Member pays 20% of
Allowed Charges after the
calendar year deductible.
For life expectancy of six
months or less
Certification is required
Age 20 and older, no charge
one time per calendar
year for preventive service
visit, metabolic panel, and
comprehensive lipid panel
H.E.L.P. Check program
pays primary member $100
for completing preventive
services visit, metabolic and
lipid panels, and health risk
assessment.
HealthChoice
High & High Alternative
Network
HealthChoice
High & High Alternative
Non-Network
HealthChoice
Basic &
Basic Alternative
HealthChoice
S-Account
Network*
26 2012 Employees Benefits Council of the Office of State Finance
Health care reform update
In 2011, state employees and their families saw several
changes in their health plans, thanks to the Patient
Protection and Affordable Care Act passed by Congress
and signed by the President. In contrast, 2012 will bring
few, if any, noticeable changes.
Once again, HMO plans will cover most preventive
services at 100 percent provided the services are done
In-network. In 2012, HealthChoice will also cover most
preventive services at 100 percent. For you, this means
no-cost access to such services as:
• Blood pressure, diabetes, and cholesterol tests
• Many cancer screenings
• Counseling from your health care provider on topics
including quitting smoking, losing weight, eating
better, treating depression, and reducing alcohol use
• Routine vaccines for diseases such as measles,
meningitis or tetanus
• Flu and pneumonia shots
• Counseling, screening and vaccines for healthy
pregnancies
• Regular well-baby and well-child visits, from birth to
age 21
(See the Health Plan Comparison section of this guide
for details.)
CAUTION:
Make Sure Your Dependents Are Eligible
Are you covering an ineligible dependent? Enrolled
ineligible dependents can result in significant and
unnecessary costs to the State and its employees. Even
the very conservative estimates put the value in the
millions of dollars.
Now is the time to make sure the dependents you
claim are eligible for state coverage.
Although no official action has been taken, an audit is
being considered. Philip K. Kraft, Executive Director
of the Employees Benefits Council of the Office of
State Finance, has directed staff to prepare for a
comprehensive dependent audit for Plan Year 2013.
A dependent eligibility audit is a controlled process
designed to preserve the integrity of an employer’s
benefit plan by identifying enrolled, but ineligible
participants. Examples include:
• Ineligible spouses
• Member forgets to inform employer of a divorce
• Once a divorce decree is issued, the employee’s
spouse is no longer an eligible dependent and
does not qualify for state benefits. If the court
orders the employee to provide the spouse with
health (or other) insurance, that coverage cannot
be through the State and will need to be obtained
from another source.
• Ineligible children
• Grandchildren, nieces and nephews (unless
employee has been granted legal custody)
• Spouses of married dependents (daughter in-law
or son in-law)
While there are financial benefits to a dependent audit, it
is by no means a popular move. However, an audit may
become necessary as a way to reduce costs in state
government, to validate insurance claims and to make
sure the State is in compliance with federal laws.
While the “honor system” is still in effect for Plan Year
2012, protect yourself by verifying the eligibility of all the
people you are claiming as dependents. If you’re unsure
whether a dependent is eligible, contact your Benefits
Coordinator or the Employees Benefits Council at (405)
232-1190 or 1-800-219-8115.
2012 Benefits Enrollment Guide 27
Mental Health Parity and Addiction Equity
Federal law, the Mental Health Parity and Addiction
Equity Act of 2008, requires health insurance providers
to include mental health and substance abuse coverage
equal to physical health coverage in terms of the
financial and treatment requirements. The law removed
differences in co-pays and removed limits on visits and
treatment days. Provisions of the law will be in effect in
all of the state’s available health plans in 2012.
Benefits Enrollment Calculator
Your benefits costs can be easily estimated using the
online Benefits Enrollment Calculator located on the
EBC web site at www.ebc.ok.gov. Be sure to choose
the monthly calculator if you are paid once a month
and the bi-weekly calculator if you are paid every two
weeks. The Benefits Enrollment Calculator can add
your benefits costs, apply your benefits allowance and
provide an estimated total, showing any out-of-pocket
expense or additional take-home pay you may realize in
your paycheck.
Important Notes about the Enrollment Calculator:
• Print your benefits calculator results for easy reference
during online enrollment.
• Use the calculator as many times as you want,
but to actually enroll you must use the Benefits
Administration System (BAS) link on the web site or
complete your paper enrollment form.
• The online Benefits Calculator provides estimates
only. Although every attempt has been made to
provide accurate information, the calculator provides
no guarantee of compensation, benefits or tax
implications.
Online Enrollment
Hit the “Easy Button” – Enroll Online!
Remember: Online Enrollment opens
October 3 and closes October 28, 2011.
Customer assistance is available October 3rd through
27th from 8 a.m. – 4 p.m. and October 28th from 8 a.m.
– 8 p.m. Assistance is also available by submitting a
help ticket through the help desk of the EBC website at:
www.ebc.ok.gov
Last year, 78 percent of state employees went to ebc.
ok.gov and used online enrollment to make their benefit
elections. Join your co-workers and discover how easy
it is to enroll online. The average enrollment takes just
a few minutes and you can log on anytime, 24 hours a
day, seven days a week during Option Period.
Online Enrollment allows you to:
• Print your confirmation of elections instantly
• Update address and telephone information online
• Change your elections and make corrections as
many times as you like, until the close of Option
Period (remember, your final election is the official
enrollment!)
1. Look for the Welcome Letter distributed by your
Benefits Coordinator. Find your User ID and
password.
2. Log on to EBC’s secure web site, www.ebc.ok.gov.
Sign on to the Benefits Administration System using
instructions found in your Welcome Letter.
3. Change password: Follow instructions to set your
personal password.
4. Choose Online Enrollment and begin.
On the home page of ebc.ok.gov, the Benefits
Administration System (BAS) access window is in the
top right corner of the screen. Inside BAS, updated
videos featuring step-by-step online enrollment
instructions are available. Online enrollment is not
currently available for newly hired employees outside of
Option Period.
Eligibility Reminder:
If you experience a qualifying life event during the
year; for example, marriage, divorce, birth or adoption,
you may be allowed to make certain changes to your
insurance elections without waiting for Option Period.
You must complete a change form within 30 days of
the life event (see page 39 for a full list), or wait until the
next Option Period to make any changes.
Remember, it is a 30-day deadline!
Help is available by phone at the Employees Benefits
Council: (405) 232-1190 or 1-800-219-8115.
28 2012 Employees Benefits Council of the Office of State Finance
Invisible Bracelet
Like a virtual medical ID bracelet, the Invisible Bracelet
may help save your life during emergencies. The early
medical alert involves an eight-digit code that appears
on a keychain fob and/or a sticker to be placed on
the back of your driver’s license. The fob can also be
attached to a child’s backpack.
If you are
unconscious or
otherwise unable
to be understood,
emergency medical
service providers
can enter your code
on a secure, HIPAA-compliant
web site
and get valuable
information in
seconds, including
your identity, medications, allergies, chronic conditions,
insurance and emergency contacts.
First responders in many communities around
Oklahoma, such as EMSA, are already trained to look
for the fob or sticker. The information they’ll find is
entered by you, so it’s important to keep the information
current. Invisible Bracelet offers “Auto Reminders” to
help you keep your health information and emergency
contacts up to date.
Employees, spouses and other eligible dependents
can take advantage of this benefit. The cost is only $3
per person, per year. So, for example, if an employee,
spouse and two children all get Invisible Bracelets,
the cost will be $12. The membership fee(s) will be
deducted during the employee’s first pay period
of 2012. The Invisible Bracelet benefit is a pre-tax
deduction for employees who choose premium
conversion.
To learn more about this innovative “Made in Oklahoma”
service or to see if the service is available in your area,
visit www.invisiblebracelet.org.
Flexible Spending Accounts (FSAs)
Want to Save More On Your Taxes?
FSAs are money-saving ways to pay for qualified health,
day care and mass transit expenses because the
accounts are funded with pre-tax dollars. Here’s how
the average person, contributing just $100 per month,
can increase their take-home pay by using an FSA:
Without FSA With FSA
Annual Salary $35,000 $35,000
FSA Deposit (annual) 0 1,200
Taxable Income 35,000 33,800
Estimated Taxes (30%) - 10,500 -10,140
Health Care Expenses - 1,200 0
Take Home Pay 23,300 23,660
Annual Increase in
Take Home Pay $360
FSAs can no longer be used to pay for some over-the-
counter drugs and health products without a
prescription. Check out the list of eligible items provided
at ebc.ok.gov in the “Flexible Spending” section.
Experience the Convenience of the
Free FSA Debit Card!
It’s fast, flexible and free! The optional Flexible Spending
Account (FSA) debit card can be used at hundreds of
merchants.
Simply present the FSA debit card to pay for medical
and dependent care expenses. The money is taken
directly from your FSA account, resulting in fewer paper
claims to file.
When using the FSA debit card, some charges may
require proof after purchase. Save your receipts!
Please Note the Following:
• FSAs have a “Use it or Lose it” rule. Simply stated, if
you have money left in your account after March 15th
of the following year, that money will be forfeited. But
don’t let that scare you. With a little planning, you can
take advantage of this tax-reducing benefit without
losing any money.
• Debit cards are not currently available for use in the
Mass Transportation Accounts. FSA debit cards are
available only in conjunction with the health and
dependent care accounts.
• You cannot enroll in a Flexible Spending Health Care
Account if you choose the HealthChoice S-Account
Plan.
Oklahoma
Company
2012 Benefits Enrollment Guide 29
• You may be restricted from enrollment in the
HealthChoice S-Account if you have funds remaining
in your FSA Health Care Account on January 1, 2012.
• In limited circumstances, you may be eligible to roll
over certain remaining amounts from your FSA Health
Care Account to your newly established HSA account.
• You can continue to participate in the FSA Dependent
Care Account or the New Mass Transportation
Account if you elect the HealthChoice S-Account
Plan.
Grace Period Extension
The IRS allows a grace period for incurring approved
expenses from your FSA. You have until March 15th of
the following year to use funds from your current year’s
account.
So go to the doctor, buy a prescription or incur any
approved expenses such as bandages, diabetes testing
supplies, and contact lens solution until March 15th,
2013 and still file for reimbursement from your remaining
2012 FSA account fund. Check out the full list of eligible
products in the Flexible Spending section of www.ebc.
ok.gov.
When calculating your FSA contribution for Plan Year
2012, it is important to plan conservatively. Calculate
based on your Plan Year estimated expenses. Do not
include the extended grace period in your calculations.
This extension may help you reduce the risk of losing
unused funds in your FSA accounts.
Add Up Your Savings with our
FSA Savings Calculator
• How much in taxes will I save?
• How much should I contribute annually?
• What expenses should I consider when calculating my
contribution?
To see how you might benefit from enrolling in an FSA,
log on to www.ebc.ok.gov and use the FSA savings
calculator. It can help you estimate your qualifying
annual expenses and calculate how much you can save
in taxes by paying for your health care and dependent
care expenses on a pre-tax basis.
Health Care Account (HCA)
By signing up for a Health Care Account,
you can set aside up to $5,000 for you
and your family’s health care related
expenses. Realize significant tax savings
on qualified, un-reimbursed expenses by paying for the
services and items pre-tax. Enroll for an HCA online or
with your paper enrollment, indicating the pay period
contribution you want deducted from your paycheck.
Some qualifying expenses include:
• Doctors visits, deductibles and copays
• Prescription drugs
• Vision care, laser eye surgery, eyeglasses or lenses
• Dental care, orthodontic expenses
• Physical therapy
As many FSA users are already aware, restrictions on
pre-tax purchases of some over-the-counter (OTC)
medications like Tylenol and Claritin took effect in 2011
and will continue to be in place for 2012. In accordance
with a provision of the health care reform law, OTC
drugs, medicines and biologicals can be purchased with
Health Care FSA funds, but only with a letter of medical
necessity from a medical provider. Also, the items can
no longer be purchased with the “Benny” debit card.
However, products like bandages and contact lens
solution will still be allowed as Benny card purchases.
Check out the list provided at ebc.ok.gov in the
“Flexible Spending” section.
HCA Monthly Minimum: $10
HCA Monthly Maximum: $416.66
30 2012 Employees Benefits Council of the Office of State Finance
Dependent Care Account (DCA)
Daycare expenses can add up quickly. By contributing
to a Dependent Care Account, you can pay for child
or adult daycare with pre-tax dollars resulting in
substantial tax savings. Monthly contributions are
deducted from your paycheck before your taxes are
calculated. Enroll for the DCA online or by paper, but be
sure to indicate your pay period contribution.
DCA Monthly Minimum: $50
DCA Monthly Maximum: $416.66
Mass Transportation Accounts (MTA )
By enrolling in this option, employees can have pre-tax
deductions directed to this account for employees to
utilize mass transit and be able to be reimbursed for
bus tokens with pre-tax funds for their commute to and
from state employment. This account is designed for
Employees’ use only. You may be reimbursed only for
the employee’s use of Mass Transit. No reimbursement
for dependents is permissible. To utilize the account,
you simply enroll any time during the plan year (this
account does not require a family status event). You
will then purchase a monthly mass transit pass from
your area provider and submit a copy of the pass along
with a claim form to EBC. You will be reimbursed once
funds are in your Mass Transit Account. The maximum
amount you can contribute is $115 a month ($1,380
annually). You are allowed to change your monthly
election during the plan year between a minimum of
$10 to the maximum of $115. You may also discontinue
the account during the year if your needs change. See
your Benefits Coordinator for additional information or
contact EBC.
MTA Monthly Minimum: $10
MTA Monthly Maximum: $115
• See additional important rules and regulations for
Mass Transit accounts on page 38 of this Guide.
Important Notes on FSA Accounts:
• You must re-enroll every year.
• Indicate your per-pay-period contribution on your
enrollment (not your annual contribution).
• View account balances and claim information on line
by logging onto the Benefits Administration System
(BAS) via the EBC website at www.ebc.ok.gov. After
logging in using your employee ID and password,
select Flexible Spending from the left menu.
• See additional important rules and regulations for
FSAs on page 37 of this Guide.
HealthChoice S-Account Plan
The S-Account Plan is a qualified high deductible health
plan to be used exclusively with a Health Savings
Account (HSA).1
• For information on participating in this account on a
pre-tax basis, contact EBC at (405) 232-1190, ext. 110.
• Please note the following:
• You cannot enroll in a Health Care flexible
spending account (FSA) if you choose the
HealthChoice S-Account Plan. You may, however,
elect either the Dependent care account and/or
the Mass Transportation account if you have a
HSA.
• You may be restricted from enrollment in the
HealthChoice S-Account if you have funds
remaining in your Health Care flexible spending
account on January 1, 2012.
• In limited circumstances, you may be eligible to
roll over certain remaining amounts from your
Health Care flexible spending account to your
newly established HSA account.2
The $1,500 individual/$3,000 family deductible for the
HealthChoice S-Account Plan must be met before any
health or pharmacy benefits are paid by the plan. There
are certain exceptions for preventive care. Refer to the
Health Plan Comparison Section for details.
1 Although OSEEGIB and the Health Savings Account (HSA)
trustee/custodian together provide health insurance benefits,
each are independent entities with separate responsibilities.
OSEEGIB expressly disclaims any fiduciary obligation to manage
the member’s HSA funds or accounts. HSA account information
concerning contributions, IRS determinations, withdrawals, or any
matters regarding the HSA is the sole responsibility of the HSA
trustee/custodian chosen by the member.
2 Confer with your tax professional for possible eligibility questions
and tax consequences of enrollment in a high deductible health plan
and health savings account.
For further information, contact OSEGIB at
405-717-8780 or toll-free 1-800-752-9475
2012 Benefits Enrollment Guide 31
Employee Life Insurance
All eligible current state employees are covered by the
HealthChoice Life Insurance Plan which provides a
$20,000 basic term life insurance policy called Basic
Life. An additional term life policy, called Supplemental
Life, is available in $20,000 units for employees who
need more coverage.
Basic Life Coverage
As a state employee, you are automatically enrolled
in Basic Life. This also includes Accidental Death and
Dismemberment (AD&D) coverage.
Supplemental Life Coverage
You can elect to increase your life insurance coverage
in $20,000 units up to a maximum of $500,000. To
increase your coverage, a Life Insurance Application
must be submitted and approved. Your application
must be approved before coverage can take effect. The
postmark deadline for submitting the Life Insurance
Application is Tuesday, November 15, 2011.
AD&D Coverage
Basic Life ($20,000) and the first unit ($20,000) of
Supplemental Life include Accidental Death and
Dismemberment coverage. AD&D coverage pays
additional benefits for the loss of life, loss of limb
or limbs, or the loss of sight. See the HealthChoice
Life Insurance Handbook for more information. The
handbook is available online at www.healthchoiceok.
com or www.sib.ok.gov.
Guaranteed Issue (New employees only)
You may enroll in life insurance coverage in an amount
up to two times your base annual salary without
completing a Life Insurance Application. See your
Benefits Coordinator for details.
How to Increase Your Life Insurance
Coverage
To increase your life insurance coverage, please
complete a Life Insurance Application and obtain your
Coordinator’s signature, if required. Mail directly to
the Oklahoma State and Education Employees Group
Insurance Board (OSEEGIB), a division of the Office of
State Finance. The address is located on the back of
the form.
For a complete description of life insurance coverage,
eligibility and benefits, please refer to the HealthChoice
Life Insurance Handbook. The handbook is available
online at www.healthchoiceok.com or www.sib.ok.gov.
Dependent Life Insurance
You have three options to choose from when purchasing
dependent life insurance coverage:
Dependent Life Premier Option
• $20,000 term life policy for spouse
• $10,000 term life policy for each child
• $1,000 term life policy for newborns to 6 months
Dependent Life Standard Option
• $10,000 term life policy for spouse
• $5,000 term life policy for each child
• $1,000 term life policy for newborns to 6 months
Dependent Life Low Option
• $6,000 term life policy for spouse
• $3,000 term life policy for each child
• $1,000 term life policy for newborns to 6 months
To enroll, complete the back of your enrollment form or
select this option during your online enrollment.
Monthly Premium
Basic Life ($20,000)
Includes AD&D . . . . . . . . . . . . . . $4.00
First $20,000 Supplemental Life
Includes AD&D . . . . . . . . . . . . . . $4.00
Additional Units of Supplemental Life
Age-Rated (Per $20,000)
Under 30 years . . . . . . . . . . . . . . . . . $0.60
30-34 years . . . . . . . . . . . $0.60
35-39 years . . . . . . . . . . . . . . $0.80
40-44 years . . . . . . . . . . . . . . $1.20
45-49 years . . . . . . . . . . . $2.00
50-54 years . . . . . . . . . . . . . $3.40
55-59 years . . . . . . . . . $5.40
60-64 years . . . . . $6.20
65-69 years . . . . . . . . . . . $10.20
70-74 years . . . . . . . . . . . . . . $17.40
75+ years . . . . . . . . . . . . . . $27.00
Dependent Life
Low Option . . . . . . . . . $2.60
Standard Option . . . . . . . . . $4.32
Premier Option . . . . . . . . . . . $8.64
Disability . . . . . . . . . . . . . . . $9.10
32 2012 Employees Benefits Council of the Office of State Finance
Assurant Freedom Preferred
www.assurantemployeebenefits.com
Deductibles
$25 per person
(Waived for
Class A Services)
$25 per person None None
100% of allowable
amounts
Includes routine
cleanings, check-ups
and some
X-rays for adults
and children, and
fluoride treatments
100% of allowable
amounts
Includes routine
cleanings, check-ups
and some
X-rays for adults
and children, and
fluoride treatments
Example Services
Copays
Sealant per tooth:
$22 copay Routine
Cleaning (once every
6 months): No charge
Topical Fluoride
Application (up to age
18): No charge
Periodic Oral
Evaluations: No charge
Example
Services /Copays
Sealant per tooth:
$15 copay
Routine Cleaning
(once every 6 months):
No charge
Topical Fluoride
Application (up to age
18): No charge
Periodic Oral
Evaluations: No charge
85% of allowable
amounts after
deductible.
Includes fillings,
some X-rays,
extractions,
periodontal care, and
some root canal oral
surgery
70% of allowable
amounts after
deductible.
Includes fillings,
some X-rays,
extractions,
periodontal care, and
some root canal oral
surgery
Example
Services/Copays
Amalgam - one
surface, permanent
teeth $32
Example
Services/Copays
Amalgam - one
surface, permanent
teeth $25
60% of allowable
amounts after
deductible
50% of allowable
amounts after
deductible
Example
Services/Copays
Root Canal,
Anterior $175
Periodontal/Scaling/
Root Planing 1-3
teeth (per quadrant)
$54
Endodontist: 15
percent discount
Example
Services/Copays
Root Canal,
Anterior $165
Periodontal/Scaling/
Root Planing 1-3
teeth (per quadrant)
$36
Speciality rider
pays specialist at set
copays.
No deductible, plan
pays 60% up to
lifetime maximum
of $2,000
No deductible, plan
pays 50% up to
lifetime maximum
of $2,000
25% discount for
Adults and Children
25% discount for
Adults and Children
Assurant Heritage
www.assurantemployeebenefits.com
Annual
Maximum
Benefit
$2,000 per person
per calendar year
$2,000 per person
per calendar year
No plan year dollar
maximum
No plan year dollar
maximum
(Requires choosing a
primary care dentist)
(Requires choosing a
primary care dentist)
Basic Care
(Class B)
Includes fillings, extractions,
periodontal care, root canal,
and oral surgery
Preventive Care
(Class A)
Includes routine cleanings,
check-ups, X-rays and
topical fluoride treatments
Major Care
(Class C)
Includes crowns, bridges
and dentures
Orthodontic Care
(Class D)
2012 Dental Plans
See the Dental Monthly
Rates on page 5. In-Network Out-of-Network Secure
Prepaid Plan
Plus
Prepaid Plan
2012 Benefits Enrollment Guide 33
Important Details
about Dental Coverage:
• Pay special attention to the plan’s participating dentists. Call to confirm your dentist accepts your
selected plan. Be specific in your questions. For example, ask if the dentist participates as a Delta
Dental PPO network provider, not just if they accept Delta Dental.
• If you choose a dentist out-of-network, you will receive lower benefits and may be subject to
additional costs.
• Dental prescriptions are covered under health plan benefits.
None
$5 office copay
applies
$25 per person
per calendar year-
Classes B & C only
$50 per person
per calendar year-
Classes A, B and C
only
$100 deductible per
person on Major
Services only
(level 4)
$25 per person
Basic Care and
Major Care
combined;
$25 per person
Preventive, Basic,
and Major Care
combined
Example Services
Copays Sealant per
tooth: $15 copay
Routine cleaning (once
every 6 months): no
charge
Topical Fluoride
Application (up to age
18): no charge
Periodic Oral
Evaluations: no charge
100% of allowable
amounts No
deductible applies
100% of allowable
amounts after
deductible
Schedule of
Covered Services
and Enrollee
Copayments:
Example Services/
Copays Routine
Cleaning: $5 copay
Periodic oral
evaluations:$5 copay
Topical fluoride
application (up to age
19): $5 copay
100% of
allowed charges
100% of
allowed charges
after the deductible
Example
Services/Copays
Root Canal,
Anterior $355 copay
Periodontal Scaling/
Root planning 1-3
teeth (per quadrant)
$71 copay
60% allowable
amounts after
deductible
50% allowable
amounts after
deductible
Schedule of
Covered Services
and Enrollee
Copayments:
Example Services/
Copays Crown-porcelain/
ceramic
substrate: $241 copay
Complete denture-maxillary
$320 copay
60% of
allowed charges
after deductible
50% of
allowed charges
after deductible
$2,280 out-of
pocket child;
$3,120 out-of-pocket
adult (24 month
treatment); excludes
orthodontic treatment
plan and banding.
60% of allowable
amounts up to
$2,000 lifetime
maximum
60% of allowable
amounts up to
$2,000 lifetime
maximum
You pay charges in
excess of $50 per
month. Lifetime
maximum up to
$1,800
50% of allowed
charges 12-month
waiting period
may apply*
No deductible or
lifetime maximum
for Network or
Non-Network
50% of allowed
charges 12-month
waiting period
may apply*
No deductible or
lifetime maximum
for Network or
Non-Network
Prepaid Plan
(Requires choosing a
primary care dentist)
PPO
In-Network and
Out-of-Network
Premier
In-Network and
Out-of-Network
PPO - Choice
Delta Dental
PPO Network
Network Provider Non Network
Provider
CIGNA Dental
www.cigna.com
Delta Dental
Example
Services/Copays
Amalgam - one
surface, permanent
teeth $21
85% allowable
amounts after
deductible
70% allowable
amounts after
deductible
Schedule of
Covered Services
and Enrollee
Copayments:
Example Services/
Copays Amalgam one
surface, primary or
permanent tooth $12
copay
85% of
allowed charges
after deductible
70% of
allowed charges
after deductible
No plan year dollar
maximum
$2,500 per person
per calendar year
$3,000 per person
per calendar year
$2,000 per person
per calendar year
$2,000 per person
per calendar year
Preventive, Basic,
and Major Care
combined
$2,000 per person
per calendar year
Preventive, Basic,
and Major Care
combined
Delta Dental Delta Dental HealthChoice Dental
www.DeltaDentalOK.org www.DeltaDentalOK.org www.DeltaDentalOK.org www.healthchoiceok.com
34 2012 Employees Benefits Council of the Office of State Finance
Disability Insurance
No one expects to become disabled, but
the financial burden can be eased by
your coverage under the HealthChoice
Disability Plan. Disability coverage pays
an amount equal to 60 percent of your
base salary up to a maximum dollar limit based on your
age, salary, and years of service from the onset of your
disability.
Eligibility
Disability benefits are available to all employees who
have completed at least one month of continuous
employment. No benefits are payable for any disability
caused by a pre-existing condition.* Claims must
be filed within one year of the date you first became
disabled.
Definition of Disability
Disability is defined as the inability to perform the major
duties of your job. After two years of disability, it is
defined as the inability to perform the duties of any job
for which you are or may become reasonably qualified
by training, education or experience.*
What the Plan Pays
The disability plan will pay a monthly income equal to
60 percent of your base pay up to a maximum (minus
offsets).
Monthly Maximum Disability Income
• Short-Term: $2,500
• Long-Term: $3,000
Benefits paid will be offset by any other income you
may receive such as Social Security Disability, Workers’
Compensation, Leave, or Disability Retirement.
When the Plan Pays
Payments begin after you have been disabled for 30
days. Short-term disability pays a benefit for the first
150 days. Generally, long-term disability pays a benefit
after 180 days of disability and continues to age 65 or
recovery, whichever is first, based on age, salary, and
years of service at the onset of your disability. Other
limitations may apply.
*For a complete description of the disability plan’s eligibility and
benefits, please refer to the HealthChoice Disability Insurance
Handbook. The handbook is available online at
www.healthchoiceok.com or www.sib.ok.gov.
Employee Assistance Program (EAP)
The EAP is a cooperative effort between employees and
administration, offering employees and their families
an opportunity to seek and receive free assistance
in resolving personal issues. Some of these issues
include family, financial, emotional, alcohol/drug abuse,
addiction, trauma, and work relationships, which
adversely affect safe and efficient performance on the
job. The EAP is available to help employees deal with
personal issues before they result in deterioration of
health, family life, or job performance. EAP specialists
provide confidential assistance, information and
referrals for employees/family members in using their
behavioral health benefit and/or finding a community
resource. EAP specialists also consult with supervisors/
managers on how employees can be referred for
assistance. For more information, contact your agency’s
Human Resource Office, review Merit Rule 530:10-21-1
through 9, or go to EBC’s web site, ebc.ok.gov, click on
OKHealth, then Wellness, then Programs.
SoonerSave
SoonerSave – Prepare for
Retirement Wisely
SoonerSave is a voluntary
long-term retirement savings
plan available to State
employees only. It is a division of the Oklahoma Public
Employees Retirement System (OPERS) and is designed
to supplement the benefit you receive from your State
retirement system. SoonerSave is comprised of two
defined contribution plans: The Deferred Compensation
457 Plan and the Deferred Savings Incentive 401(a)
Plan. When you contribute money to SoonerSave, your
contribution is deposited in the Deferred Compensation
457 Plan. As an incentive to contribute to SoonerSave,
the State will contribute $25 per month to the Deferred
Savings Incentive 401(a) Plan.
SoonerSave is an excellent way to defer federal and
state taxes from your current income while saving for
the future. In both plans, contributions and any earnings
grow tax-deferred until money is withdrawn, usually
during retirement when the participant is typically
receiving less income and may be in a lower tax bracket
than while working.
A few reasons to join SoonerSave today include:
• Easy Enrollment and Savings—You can now enroll in
SoonerSave using the same Online Enrollment process
that you use to make your other benefit elections. Just
decide how much you want to contribute and how
you want it invested—then you are on your way to
investing for your retirement through convenient payroll
deduction.
You may also enroll in SoonerSave by going directly
to http://www.dcprovider.com/oklahoma/ and entering
your social security number and password (savenow).
• Tax Savings—Your contributions are deducted from
your paycheck before federal and state income taxes
are calculated—lowering your taxable income. Plus,
your contributions and any earnings grow on a tax-deferred
basis.
2012 Benefits Enrollment Guide 35
• Money from the State of Oklahoma—You will receive a
$25 state contribution each month just for participating
in SoonerSave.
• Tax Credit—Some SoonerSave participants may be
eligible for a tax credit to help save for tomorrow by
reducing taxes today. The amount of credit depends
on your adjusted gross income and filing status (e.g.,
single, married, head of household). To learn more
about the tax credit, you should consult your tax
advisor or visit www.irs.gov and search for “Saver’s
Credit” or Form 8880.
Are you already participating in
SoonerSave? Great! You’ve taken
the first step to preparing yourself
for retirement. Now, you may want
to take the next step and increase
your contribution amount using the
Online Enrollment process. Increasing your contributions
to SoonerSave by even a small amount could make a
big difference in your long-term retirement savings plan.
The table below illustrates the impact an increased
contribution could have on your account balance and the
benefit you receive from your account when you retire.
SoonerSave continued
$50/month $25/month $75/month $44,177 $279.48
$100/month $25/month $125/month $73,628 $465.81
$150/month $25/month $175/month $103,079 $652.13
$200/month $25/month $225/month $132,530 $838.45
Employee
Contribution
Amount
Employer
Contribution
Amount
Total
Contribution
Amount
SoonerSave
Balance After 20
Years*
Monthly Benefit for
20 Years (Before
Tax Withholding)*
* FOR ILLUSTRAT IVE PURPOSES ONLY. This hypothetical illustration does not represent the performance of any investment options. The
accumulation stage assumes an 8% rate of return, reinvestment of earnings and no withdrawals. The payout stage assumes 12 monthly
payments per year with a 4.5% rate of return. Withdrawals of tax-deferred accumulations are subject to ordinary income tax. This illustration
does not reflect any charges, expenses or fees that may be associated with your Plan. The tax-deferred accumulations shown above would
be reduced if these fees had been deducted. In order to properly plan for your retirement years, OPERS strongly encourages you to consider
participating in SoonerSave (if you are eligible) as a way to supplement the income you will receive from your defined benefit plan and Social
Security. For more information about SoonerSave or to update your beneficiary information, call 1-800-733-9008 or (405) 858-6781. You can
also obtain information, change your contribution amount or find enrollment forms by visiting www.soonersave.com. SoonerSave is a division
of the Oklahoma Public Employees Retirement System.
36 2012 Employees Benefits Council of the Office of State Finance
General
Enrollment in a medical or dental plan does not guarantee that a
particular doctor, dentist, clinic, or hospital will remain in your plan’s
network for the entire year. You enroll with the PLAN and not the
provider. If your provider terminates his or her contract during
the Plan Year, this does not allow you to change medical or
dental plan carriers. These benefits are effective January 1, 2012.
Keep this book as a reference throughout the year. This booklet
is only intended to be a brief summary of certain provisions of the
State of Oklahoma Employee benefit plans. In the event of a conflict
between the booklet and the laws of the State of Oklahoma or
administrative rules of the Employees Benefits Council (Council) and
the Oklahoma State & Education Employees Group Insurance Board
(Insurance Board), the laws and administrative rules shall govern in
all cases.
Dental
Out-of-network benefits may allow dentist to balance bill.
Balance Billing – the practice of a provider charging full fees and
billing the member for the portion of the bill insurance doesn’t cover.
Orthodontic benefits on the PPO options are typically only available
for dependents under the age of 19 or anyone with TMD. Contact
the plan to determine limits on Orthodontic benefits prior to
enrollment.
If new hires and/or new enrollees did not have group dental
coverage in effect prior to becoming covered under HealthChoice
Dental; and Assurant Freedom PPO a 12-month waiting period is
applied for orthodontic services.
*No waiting period applies for orthodontic benefits under the Delta
Dental plans.
See each dental plan’s website for a list of the dentists participating
in each plan’s network.
Delta Dental and Assurant Freedom Preferred both have statewide
and nationwide networks and will have the same benefits if
treatment is provided out of state.
**There is no applicable copayment schedule for Assurant Plan
Specialist services. Assurant Plan Specialists reduce their charges
as follows: a 15 percent discount off normal retail charges for
Endodontist and a 25 percent discount for any other Plan Specialist
including Orthodontist.
HealthChoice Dental Notes:
You are responsible for non-Network amounts that exceed the
Allowed Charges and for all non-covered services. Age limits and
restrictions may apply, please consult each plan.
Orthodontic benefits are only available to dependents under the age
of 19 with certification required for members greater than 19 years
of age. Contact the plan to determine limits on orthodontic benefits
prior to enrollment.
*If you are a new hire and/or a new enrollee and you did not have
group dental coverage in effect prior to becoming covered under
HealthChoice Dental; a 12-month waiting period will be applied to
orthodontic services.
See each dental plan’s website for a list of the dentists participating
in each plan’s network.
Consumer Information & Annual Notices
The Council and the Insurance Board comply with the HEALTH
INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996
known as HIPAA. The Council, the Insurance Board and each HMO,
dental, and vision plan offered to State employees has a Privacy
Notice which describes the organization protections and acceptable
uses of information. To obtain a Privacy Notice from a particular
plan, contact the plan directly or contact the Council. HIPAA also
provides you and your dependents certain rights to enroll if you
lose your group health plan coverage. HIPAA also prohibits a
group health plan from keeping you (or your dependents) out of
the plan based on anything related to your health. Finally, HIPAA
also gives you the right to buy certain individual health policies (or
in some states, to buy coverage through a high-risk pool) without
pre-existing condition exclusions. The HealthChoice medical
products offered by the Insurance Board are exempt from most of
the portability provisions of HIPAA including, but not limited to, the
following: limitations on pre-existing conditions, special enrollment
rights, discrimination based upon a health factor, standards for
mothers and newborns, mental health parity, and reconstructive
mastectomies. See the section on General Eligibility Information
for more details. The WOMEN’S HEALTH & CANCER RIGHTS ACT
of 1998, a Federal Law, provides benefits for mastectomy related
services including reconstruction and surgery to achieve symmetry
between the breasts, prostheses, and complications resulting
from a mastectomy (including lymphedema). The 1998 Guidance,
Questions and Answers, and Notice Requirements under WHCRA
(November 1998), can be obtained by calling 1-866-444-3272. The
BREAST CANCER PATIENT PROTECTION ACT, an Oklahoma State
Law, provides for at least 48 hours of inpatient care following a
mastectomy and not fewer than 24 hours following a lymph node
dissection. The NEWBORNS & MOTHERS ACT of 1996, a Federal
Law, requires the availability of a hospital stay of at least 48 hours
in connection with a vaginal delivery and not less than 96 hours
with a cesarean delivery. The PROSTATE CANCER PROTECTION
ACT, an Oklahoma State Law, provides for an annual screening for
early detection of prostate cancer in men age 50 and over and in
men from age 40-50 who are in high-risk categories. The Oklahoma
Prostate Surgery Side Effects Law provides that all health benefit
plans offered by OSEEGIB & EBC shall provide coverage for side
effects that are commonly associated with radical retropubic
prostatectomy surgery, including, but not limited to impotence
and incontinence, and for other prostate related conditions. THE
MANDATED BENEFIT FOR OB/GYN COVERAGE LAW requires any
health benefit plan offered in the state of Oklahoma which provides
medical and surgical benefits to also provide coverage for routine
annual obstetrical/gynecological examinations. The law does not
diminish already allowed health benefit diagnostics. In addition
the law also specifies that obstetrical/gynecological examinations
do not have to be performed by an obstetrician, gynecologist, or
obstetrician/gynecologist. If you have a problem which cannot be
resolved through your benefit plan’s grievance process, you may
have remedies with the Oklahoma State Department of Health,
Oklahoma Department of Insurance, or a remedy of law. Once you
become covered under a group health plan, you have certain rights
under the CONSOLIDATED OMNIBUS BUDGET RECONCILIATION
ACT of 1985 (COBRA). COBRA continuation coverage can become
available to you when you would otherwise lose your group health
coverage. It can also become available to other members of your
family who are covered under the Plan when they would otherwise
lose their group health coverage. For additional information about
your rights and obligations under the Plan and under federal
law, you can contact the Council or the Insurance Board. You
may also have rights under the Uniformed Services Employment
and Reemployment Rights Act (USERRA). USERRA protects
the job rights of individuals who voluntarily or involuntarily leave
employment positions to undertake military service. The law also
prohibits employers from discriminating against past and present
members of the uniformed services and applicants to the uniformed
services. See your agency for more information.
Benefits Details
2012 Benefits Enrollment Guide 37
Continued on Page 38
General Eligibility Information
The following are rules of eligibility that apply to commonly occurring
situations. The rules are listed in no particular order. This is not an
exhaustive list. Any active state of Oklahoma employee scheduled to
work at least 1,000 hours per year is eligible for benefits coverage if
he/she is not a temporary or seasonal employee. New Hire coverage
is effective on the first day of the month following the entry-on-duty
date. Coverage ends on the last day of the termination month.
All eligible dependents must be covered when one dependent is
covered under health, dental, or vision insurance unless proof of
other group coverage is provided. Eligible dependents can include
a spouse, children up to the age of 26 and incapacitated or totally
disabled children of any age if their incapacity occurred and was
verified prior to age 26. Two State employees cannot claim coverage
for the same dependents for health, dental, and vision benefits. The
Working Families Tax Relief Act of 2004 changed the definition of
dependent for federal income tax purposes, effective January 1,
2005. The IRS indicates that the change is not intended to affect
the coverage of dependents under employer sponsored medical
plans. However if you cover dependents, EBC suggests you obtain
professional tax advice when completing your income tax return(s).
Thirty-day written notice is required to reinstate coverage.
Electing a TRICARE Supplement Plan
Electing to purchase a TRICARE supplement plan means that
TRICARE will be primarily responsible for your medical coverage and
the supplement plan will be secondarily responsible for coverage. By
your election, you submit to the eligibility rules of TRICARE and the
TRICARE Supplement plan. These rules may be different from the
rules of eligibility created by the State of Oklahoma. Medicare may
become the primary insurer upon attaining eligibility for Medicare.
Changes to Benefit Plan Elections
Benefit elections made during the Option Period are generally
irrevocable. Changes can be made to Option Period elections only
if the change is authorized and consistent with Internal Revenue
Service regulations. If you experience an event which you believe
qualifies you to change your benefit elections, contact your Benefits
Coordinator within 30 days of the event. Life events that qualify
you to change your benefit elections include: marriage, birth,
adoption or placement of an adopted child, loss of other coverage,
change in marital status, change in the number of dependents,
change in employment status of employee, spouse or dependent
that affects eligibility, event causing employee’s dependent to
satisfy or cease to satisfy eligibility requirements, change in place
of residence of employee, spouse or dependent (HMO coverage),
commencement of or termination of adoption proceedings,
judgments, decrees or orders, Medicare or Medicaid, significant
cost increases (limited to Dependent Care Account using unrelated
care provider), changes in coverage of spouse or dependent under
other Employer’s plan (except HCA), FMLA Leave, or other such
events, which may permit such modification of election under the
IRS consistency rule as found in Treasury Regulations 1.125-4 and
in accordance with other applicable and prevailing Internal Revenue
Code regulations promulgated under, and in accordance with EBC
and OSEEGIB rules and regulations.
Flexible Spending Accounts Information
These accounts let you set aside money from your paycheck, pre-tax,
to pay for planned dependent care charges and expected
out-of-pocket healthcare expenses. You must enroll each Option
Period or you lose the account. Plan carefully when deciding your
contributions. Direct deposit of your reimbursements into the
same account as your payroll deposit is required by state law. If
you terminate employment with the state, any daycare or medical
services must be incurred prior to the last day of your termination
month. If you are not on active payroll (on some type of leave) it
is your responsibility to mail in your pledged contribution. Viewing
your account information is easy using the EBC website. For further
information on allowable expenses see EBC’s website at www.ebc.
ok.gov. Reimbursement can also be made for expenses incurred
by any participant during the Grace Period. The “Grace Period” is
the period from the end of the Plan Year through March 15th of the
subsequent Plan Year during which reimbursable expenses can
be incurred and attributable to the previous Plan Year’s account
balance. The final payment of benefits for any Plan Year may be
made following the close of such Plan Year based on accepted
claims filed with the Plan Administrator no later than the end of
the Run Out Period. The “Run Out Period” means the ninety (90)
day period following a Plan Year in which claims can be made for
reimbursable expenses incurred during the Plan Year. You cannot
pay for prior year expenses from current year account funds. All
expenses use the date of service, not the date they are paid for
eligibility purposes.
Debit Cards
The Council will reimburse an FSA participant for eligible expenses
incurred through use of the participant’s debit card provided the
participant properly activates the debit card, properly substantiates
the claim for expenses, and abides by the terms of use of the
debit card. The Council reserves the right to set the fee charged to
participants for use of the card, waive the annual fee, discontinue
use of the debit card, or require paper substantiation of expenses.
The rules of eligibility for Dependent Care Accounts and Health Care
Accounts apply to participants using the debit card. Upon demand
a participant shall immediately refund any overpayment made by the
Plan Administrator. Likewise, items charged to a debit card that are
unacceptable to the Plan Administrator will require a participant to
immediately refund such an overpayment to the Plan Administrator.
Amounts remaining in a participant’s healthcare and/or dependent
care accounts following final payment of all healthcare and/or
dependent care expenses incurred during the periods described in
OAC 87:10-25-9(b) shall be forfeited to pay administrative expenses
of the Flexible Benefits Plan.
FSA Health Care (Medical) Account Information
You spend your own money for after-insurance, qualified medical
expenses, deductibles, copays and certain over-the-counter items.
These expenses may be eligible for reimbursement according to
the IRS Code, enabling you to submit a claim voucher with the
appropriate documentation and receive reimbursement from your
own tax-free account. Attach the itemized bill and/or the Insurance
Explanation of Benefits (HealthChoice State Plan or Dental Indemnity
Plan EOB) to your signed EBC Expense Reimbursement Voucher
(claim form) and mail to the address on the form. Funds will be
disbursed for the amount requested within ten days of receipt if you
submit all required documentation. Check out the list of approved
over-the-counter items on the EBC website. Documentation required
for approved OTC items is the computerized receipt, name of
item, date of purchase, and amount paid. Pharmacy labels need to
include the printed name of the drug. The date of service is the date
you incur the expense (i.e. date you drop off the prescription at the
pharmacy, date you receive the medical care). This date must be
during the plan year and while actively participating in the program
(making monthly contributions). Claim deadlines are Fridays, at 1:00
p.m. (Subject to change during holidays).
FSA Dependent Care Account Information
If you have an eligible dependent (children 12 or younger who
have been included on your income tax return or any other eligible
dependent person physically or mentally incapable of self-care) who
spends at least eight hours a day in your home, you may want to
participate in the Dependent Care Flexible Spending Account. This
account pays daycare provider expenses while you and your spouse
work up to a combined calendar year total of $5,000. The daycare
provider cannot also be your tax dependent.
The individual calendar year limit is $2,500. Form 2441 must still be
filed with your taxes. You can receive reimbursement for the amount
you have currently deposited in your Dependent Care Account. With
proof of payment and the dates of service your daycare provider is
38 2012 Employees Benefits Council of the Office of State Finance
no longer req